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Continuing the Progress: 

Enrolling and Retaining 
Low-Income Families and Children 

in 
Health Care Coverage 




CMS 

Centers for 
Medicare & Medicaid Services 



CM 

lx> 91 TABLE OF CONTENTS 



r3 



INTRODUCTION i 

I. MEDICAID APPLICATION AND ELIGIBILITY DETERMINATION PROCESSES . . .1 

A. Medicaid Application Process 1 

1 . Minimum Application Requirements 1 

2. Applications: What Else Can Be Done? 6 

B. Medicaid Eligibility Determination Process 9 

1. Minimum Eligibility Requirements 9 

2. Eligibility Determinations: What Else Can Be Done? 11 

II. MEDICAID RENEWAL AND TERMINATION PROCESSES 13 

A. Maintaining Eligibility during Medicaid Redeterminations or "Renewals" 13 

1. Minimum Renewal Requirements 13 

2. Renewals: What Else Can Be Done? 15 

B. Medicaid Eligibility Termination Process 18 

Minimum Termination Requirements 18 

in.TANF/MEDICAID DELINKING 21 

A. Application and Enrollment 21 

B. Determining EligibiUty for TANF and Medicaid 23 

C. TANF Denials and Terminations: Effects on Medicaid 23 

D. Computer Systems 24 

rV. MEDICAID ELIGIBILITY POLICIES AND EXPANSIONS 27 

A. Minimum Requirements 27 

B. Policies and Expansions: What Else Can Be Done? 28 

V. PROGRAM MONITORING BY STATES 33 

A. Minimum Requirements 33 

B. Monitoring Strategies 33 

C. MEQC and Strategies to Aid Simphfication Efforts 35 

VI. TABLE ON SIMPLIFICATION EFFORTS 37 

CONCLUSION 55 



44 



INTRODUCTION 

In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) was signed 
into law. This comprehensive bipartisan welfare reform plan dramatically changed the nation's welfare 
system by creating the new Temporary Assistance for Needy Families (TANF) program. TANF replaces 
the former Aid to Families with Dependent Children (AFDC) and Job Opportunities and Basic Skills 
Training (JOBS) programs. The same legislation made a critical change in Medicaid eligibility by 
severing the automatic link between eligibility for cash assistance for families and children and 
Medicaid. 

Delinking eligibility for cash assistance and Medicaid has provided new opportunities for States to 
offer health care coverage to low-income families regardless of whether the family is receiving cash 
assistance. Families with incomes and resources below certain State-established thresholds are 
guaranteed eligibility for Medicaid under Federal law, and States have new flexibility under the law to 
expand Medicaid to cover more low-income families. Several States have taken advantage of this new 
flexibihty. 

The delinkage of cash assistance and Medicaid, however, also has created new challenges for States 
and the people they serve. In the past, most low-income families first learned about Medicaid when 
they applied for AFDC. Under current law, however. States must ensure that low-income families have 
access to Medicaid, regardless of their connection to the cash assistance system. That is, families must 
have the ability to learn about and enroll in Medicaid even if they are not seeking cash assistance. 
Further, families who no longer receive cash assistance need to be informed that they may remain 
eligible for Medicaid, and State systems must be in place to ensure that eligible families retain their 
health care coverage. Medicaid coverage provides critical health security to families who are moving 
into the workplace as well as to families who have not received cash assistance and work at jobs that 
do not offer affordable health coverage. 

In March of 1999, the Department of Health and Human Services (DHHS) published a guide titled 
Supporting Families in Transition to assist State officials and others in understanding Medicaid 
eligibility, enrollment, redetermination, notice, appeal rights, and other program and policy issues in 
the context of the new TANF program. In 1999, DHHS reviewed State Medicaid application and 
eligibility policies and procedures in all 50 States, plus the District of Columbia and some Territories. 
Working closely with States, we have analyzed the findings of those reviews and have identified 
practices that need improvement as well as some promising practices that will be interesting models for 
other States. 

This guide is part of the Department's ongoing effort to work with States to ensure that low-income 
families and children have access to health benefits. It is intended to serve four major purposes: 

First, to assist State officials and others in understanding what is required of States in the administration 
and operation of their Medicaid application and eligibility determination processes. Our goal is to 
ensure that the requirements under the Federal rules and regulations are clearly stated and understood. 



Second, to provide technical assistance and guidance on options available to States to streamline 
application and eligibility determination processes consistent with the principles of both simplicity of 
administration and program integrity. Again, we want to ensure that States are aware of the options 
available under Federal law to help them continue their efforts to simplify the application and 
eligibility determination processes and to extend their efforts to families as well as children. Most 
States have simplified the enrollment for children in SCHIP and Medicaid but have not adopted similar 
methods for families. 

Third, to provide States with guidance on a range of issues and process concerns specific to 
Medicaid/TANF delinkage, including the updating of computer systems. We identified issues that arose 
in the onsite State reviews and provide concrete suggestions, based on State practices, for addressing 
barriers to program participation. 

Fourth, to provide State officials with an explanation of how States may use the flexibility in the law to 
expand coverage of low-income families and children and simplify their Medicaid eligibility rules. We 
hope that disseminating information about promising practices being tried throughout the country will 
help States move beyond the challenges of delinkage of Medicaid and cash assistance to consider ways 
to make health care coverage available to more low-income families. 

We recognize that State officials and others may have questions regarding the policies outlined in this 
guide. To address these questions, we have established an electronic mailbox to which individuals may 
submit questions. Questions should be sent to: MedicaidEligibility@cms.hhs.gov. The Centers for 
Medicare and Medicaid Services (CMS, formally the Health Care Financing Administration) staff will 
attempt to respond to all questions in a timely manner. 

The guide is organized into six chapters: 

• Medicaid Application and Eligibility Processes. Chapter one explains Medicaid's statutory and 
regulatory requirements concerning the application and eligibility determination processes. It includes 
a restatement of Medicaid policy regarding requests for Social Security numbers and 
citizenship/immigration information of household members not applying for benefits and a 
clarification of policy regarding requests for paternity and third party information. In addition, it 
reviews options States can take to simplify the application process to remove barriers to participation. 

• Medicaid Renewal and Termination Processes. Chapter two clarifies Federal policy regarding 
redetermination or "renewal" of Medicaid for families including the frequency of reviews and the 
required information and provides information on how States can simplify the redetermination 
process. It also restates Federal policy regarding terminations. 

• Medicaid/TANF Delinking. Chapter three addresses specific concerns and barriers that States and 
CMS have identified with respect to efforts to delink Medicaid from TANK A major focus of the 
chapter is on the basic requirements that State eligibility determination systems must meet in order to 
ensure that Medicaid procedures are properly delinked from the TANF program. 



• 



Medicaid Eligibility Policies and Expansions. Chapter four explains how the flexibihty in the 
Medicaid law provides States with the opportunity to expand coverage for low-income families and 
simplify eligibility rules, and profiles some States that have taken advantage of this flexibility. 

' Program Monitoring by States. Chapter five contains information to help ensure program integrity, 
including ensuring that local offices correctly apply State policies and procedures. It describes 
Federal financial participation that is available for monitoring and oversight activities that can aid in 
simphfying and improving program administration. 

State Simplification Efforts. Chapter six contains four tables summarizing State simplification 
efforts. 



m 



Chapter I 



MEDICAID APPLICATION AND ELIGIBILITY PROCESSES 



The Medicaid application process typically 
is a family's introduction to the program. 
As such, it plays a key role in determining 
whether or not the family successfully obtains 
coverage through Medicaid. If the application 
process is simple and easy to complete, a family 
is more likely to complete it. By the same token, 
if the process is complicated, because other 
programs are involved, a family may be deterred 
and not complete the process. 

Some States and local governments continue to 
use the application process for one program such 
as Medicaid to also determine eligibility for other 
benefit programs such as cash assistance, child 
care and Food Stamps. This "one stop shopping" 
approach presents both advantages and 
disadvantages for low-income families. Because 
different programs have different eligibility 
requirements, applications and the application 
process can become complicated. However, there 
has been a shift to present Medicaid as a health 
care program separate and distinct from the 
welfare system. Marketing Medicaid as a separate 
program presents States and local governments 
with new challenges and decisions. 

Most States have simplified the Medicaid 
application process for children by adopting mail- 
in applicafions and streamlined documentation 
requirements. However, these policies often have 
not been extended to families applying for 
Medicaid. Under Federal law. States have the 
ability to adopt the same strategies that they have 
used to simplify their application process for 
children to the application process they use for 
determining family eligibility. 

This chapter outlines the statutory and regulatory 
requirements under Medicaid concerning the 
application and eligibility determination 
processes that States must follow. To help State 



officials and others considering strategies for 
simplification, this chapter also identifies 
programmatic options designed to promote the 
enrollment of eligible low-income families with 
children. 

A. Medicaid Application Process 

The results of a national survey conducted by the 
Henry J. Kaiser Family Foundation show that 
many low-income parents misunderstand the 
delinkage of Medicaid and TANF, and most want 
a more user-friendly Medicaid enrollment 
process. 1 According to the Kaiser survey, the top 
three strategies that would make low-income 
parents more likely to enroll their children 
include mail-in or phone-in enrollment; 
immediate enrollment (with completion of forms 
later); and extended office hours for application. 
Parents also said they would be much more likely 
to enroll if they could apply when their children 
enrolled in the school lunch program or if they 
could apply at more convenient locations within 
their community. Some States have adopted these 
enrollment strategies to help more families access 
Medicaid. States also are increasing their 
outreach and marketing efforts to improve public 
understanding about Medicaid eUgibility rules 
and to reinforce the value of Medicaid as 
providing health care coverage. 

1. Minimum Application Requirements 

Federal law requires that Medicaid eligibility be 
determined in a manner consistent with simplicity 
of administration and in the best interests of 
recipients (Section 1902 (a)(4) and (19) of the 
Social Security Act). 



^Medicaid and Children: Overcoming Barriers to 
Enrollment, Findings from a National Survey, the Kaiser 
Commission on Medicaid and the Uninsured, January 2000. 



Opportunity to Apply. Under CMS regulations, 
the State agency must afford an individual the 
opportunity to apply for Medicaid without delay 
(42 CFR 435.906). TANF or other program 
requirements or actions must not have the effect 
of delaying or deterring application for Medicaid. 

Medicaid Application Forms. CMS regulations 
require a written application for Medicaid on a 
form prescribed by the State Medicaid agency 
(42 CFR 435.907). The application must be 
signed under penalty of perjury. States have 
considerable flexibility in designing the form or 
forms they will use. A form must solicit the 
information the State needs to make a Medicaid 
eligibility determination and, at the same time, be 
designed "in a manner consistent with the 
simplicity of administration." 

Online Applications and Electronic Signatures. 

States may use computerized or online Medicaid 
applications provided they have in place safe- 
guards that restrict the use or disclosure of 
information about applicants or recipients to 
purposes directly related to the administration of 
the Medicaid program. CMS suggests that States 
use an automatic encryption process that safe- 
guards the confidentiality of the information 
consistent with CMS 's internet security policy 
posted on the web at: 

www.hcfa.gov/security/isecplcy.htm . 



Electronic signatures are permitted as long as 
they are authorized by State law. However, 
adequate safeguards must be in place to protect 
the confidentiality of the information collected in 
accordance with Federal law (Section 1902(a)(7) 
of the Act). 

Documentation Requirements. Surveys and 
reviews have revealed that a leading reason why 
eligible families fail to successfully enroll in 
Medicaid is that the families do not supply State- 
required documentation. Federal law imposes 
only one documentation requirement for Medicaid: 
individuals seeking coverage who are not citizens 
or nationals of the United States must provide 
proof of alien or immigration registration from 
the Immigradon and Naturalization Service (INS), 
or other documents that the State determines 
constitute reasonable evidence of satisfactory 
immigration status. 



Rhode Island: Self-Help 

Rhode Island's Providence Regional Center 
provides a self-help area for clients in the main 
waiting room. The self-help area includes 
forms, a free copy machine and drop boxes for 
submittal of apphcations. It allows applicants 
and recipients to provide documents, report 
changes and gather information without 
waiting to see a worker. 



Documentation Checklist 



Documentation 
Requirements for 
Applicants 


Federal Requirements to 
Provide Documentation 


State Option to Allow 
Self-Declaration 


Immigration status for 
qualified aliens 


X 




Cifizenship 




X 


Income 




X 


Resources 




X 


Date of birth 




X 


Residency 




X 


Social Security Number 




X 


Child care expenses 




X 



A 



States may require families to provide other 
relevant documentation, including proof of income 
and residency, but this documentation is not 
required by Federal law. If a State does require 
families to provide additional documentation, the 
request for documentation must be limited to 
elements that are relevant to eligibility or third 
party payment. 

States have found that they can effectively 
preserve program integrity without requiring 
additional documentation from families. For 
example, States can verify financial eligibility 
through employers, banks and other collateral 
contacts. States that want to confirm the reliability 
of using self-declaration of income and resources 
also may use Medicaid Eligibility Quality Control 
(MEQC) pilot projects or other targeted studies 
on a Statewide basis or in a sub-State area. This 
option is described in CMS 's September 12, 
2000, letter to State Quality Control Directors 
(see 

http://www.hcfa.gov/medicaid/smd91200.htm .). 



Self -Declaration of Income and 
Resources 

More States are turning to self-declaration of 
income and resources, as the chart attached 
to this guide shows. As of December 2000, 
Arkansas, Florida, Georgia, Idaho, Kentucky, 
Maryland, Michigan, Oklahoma, Vermont 
and Washington use self-declaration of 
income for children's health coverage under 
Medicaid and SCHIP; Alabama, Arizona and 
Wyoming rely on self-declaration of income 
for their separate SCHIP program. 



States that require documentation must clearly 
inform the applicant what documentation to 
provide and what forms of proof are acceptable. 
Document check lists or other written notices of 
documentation requirements are very helpful in 
ensuring that documentation requirements are met, 
especially if they are provided before a family 



mails in the application or arrives at a local office. 
Also, States can improve participation in Medicaid 
by offering assistance in obtaining required 
documentation, providing facilities for copying 
required documentation, and following up with 
applicants to ensure that they submit any needed 
documentation. 

Requests for Social Security Numbers (SSNs) 
and Citizenship/Immigration Information. 

Concerns about disclosing family members' Social 
Security Numbers (SSNs) and citizenship or 
immigration status can deter eligible individuals 
from applying for Medicaid. These concerns 
appear to stem from uncertainty among immigrant 
families and others regarding the confidentiality 
of information they provide to States. 

Under Federal rules, applicants for Medicaid 
(including Medicaid expansion programs under 
SCHIP) must disclose their SSNs (though they do 
not have to show the card) as a condition of 
eligibility (Section 1137). The State is required to 
verify the SSN with the Social Security 
Administration. States use the SSN to help 
complete the Income and Eligibility Verification 
System (lEVS) income verification process 
required by law. The State may assign an alternate 
identifier for a person who expresses a religious 
objection to furnishing a SSN, or for an alien not 
in a satisfactory immigration status who is 
seeking emergency services. 

States may not require non-applicant household 
members to furnish their SSNs as a condition of 
the applicant's eligibility. To do so would violate 
Federal law and could deter eligible individuals 
with immigrant family members from applying 
for Medicaid. We recognize that voluntary 
disclosure of a parent's SSN may contribute to a 
speedier determination of a child's eligibility (as a 
means of verifying family income) and alleviate 
burdensome paperwork requirements for families 
and the agency. However, if a State requests a 
SSN from a non-applicant, it must: (1) make 
clear that the disclosure of the SSN is voluntary; 
(2) inform the applicant how the information will 
be used; and (3) advise the applicant that the 



application will not be denied if the non-applicant's 
SSN is not provided. 



Obtaining Social Security Numbers 

Recently published SCHIP regulations allow 
States to require the child's SSN as a condition 
of eligibihty for separate SCHIP programs 
effective August 24, 2001. Different rules for 
SSN's under SCHIP and Medicaid present 
challenges to States trying to design simple 
and understandable joint applications for 
children. CaUfomia's approach meets the legal 
requirements. California's joint 
Medicaid/SCHIP (the State's Title XXI 
program is called Healthy Famihes) 
apphcation for pregnant women and children 
says, "Tell us about the children under 19 
and/or the pregnant woman who want health 
coverage" and asks for the SSN and/or 
immigration status for these applicants. The 
form states, "Social Security Numbers are not 
required for Healthy Families or for persons 
who want emergency or pregnancy related 
services only." Families often will not know 
when they complete the form whether their 
children will qualify for Healthy FamiUes; if a 
family does not provide the child's SSN on the 
application, and the child turns out to be 
Medicaid ehgible, the California agency will 
follow up with the family to obtain the child's 
SSN. 



As with SSNs, only persons applying for Medicaid 
are required to document their citizenship or 
immigration status. States may not: (1) require 
parents or other household members who are not 
applying for themselves to disclose this 
information; (2) make this disclosure a condition 
of eligibility for the applicant; or (3) deny the 
application because non-applicant household 
members do not provide the information. 

CMS recently joined with the Administration for 
Children and Families, the Food, Nutrition, and 
Consumer Services, and the Office for Civil Rights 



(OCR) to provide policy guidance in this area. 
You can refer to the September 21, 2000, letter to 
health and welfare officials for detailed information 
on SSN and citizenship/immigration requirements 
under the Medicaid, TANF and Food Stamps 
programs. A copy of the letter is posted on CMS 's 
website at 

www.hcfa.gov/medicaid/shw92100.htm. 

Paternity and Assignment of Rights as a 
Condition of Eligibility. Parents of children bom 
out of wedlock applying for Medicaid for them- 
selves and their child/children must cooperate in 
establishing paternity and pursuing third party 
benefits and assign rights to medical support and 
payments (42 CFR 433.147) as a condition of 
their eligibihty (but not the ehgibility of the child). 
A State may not require cooperation, however, if 
the parent has good cause for not cooperating 
(e.g., in cases of domestic violence). Furthermore, 
non-cooperation by the parent does not affect the 
child's eligibility for Medicaid. States must inform 
applicants of the exemptions for good cause and 
advise applicants that their decision whether or 
not to pursue support will not affect their child's 
eligibility for Medicaid. 

States cannot require information about paternity 
if a parent or other individual files an application 
for Medicaid only on behalf of a child and can 
choose not to ask about it. (However, the State 
must ask about health insurance that the child 
may have and the State must have laws in effect 
that automatically assign to the State the child's 
rights to third party payment by health insurers.) 
If the application asks for paternity information 
in situations where it is not required (e.g., in a 
child-only applicadon), the form must make it 
clear that providing the information is optional. 

In those situations where a State Medicaid agency 
must ask about paternity and medical support (for 
example, because the parent is applying for herself 
as well as for her child), it is sufficient to simply 
obtain a statement that the parent (if non-exempt) 
agrees to cooperate. The Medicaid agency does 
not have to soUcit detailed and specific information 
about the absent parent as part of its apphcation 



process. Instead, it may provide parents with 
information on how to follow up with the Child 
Support Enforcement (CSE) agency, or the 
Medicaid agency, acting for the CSE agency, may 
follow up after the application process is complete. 

There are no Federal requirements for cooperating 
with CSE under the SCHIP rules. If a State chooses 
to implement SCHIP through Medicaid, the 
Medicaid cooperation requirements apply because 
the SCHIP enrollees are Medicaid beneficiaries. 
For more information, see the CMS website at 

www.hcfa.gov\Medicaid\smdl21900.htm. 

Linguistic Access. Medicaid appUcations, notices, 
and other program information must comply with 
hnguistic access requirements under Title VI of the 
Civil Rights Act. In order to ensure comphance 
with Title VI, recipient/covered entities must take 
steps to ensure that hmited English proficiency 
(LEP) persons who are eligible for their 
programs or services have meaningful access to 
the health and social service benefits they 
provide. The most important step in meeting this 
obUgation is for recipients of Federal financial 
assistance to provide the language assistance 
necessary to ensure such access, at no cost to the 
LEP person. 



Maine: Non-English Applications 

Maine prints the informational portions of its 
Cub Care apphcation in thirteen languages 
spoken by residents: English, French, Spanish, 
Amharic, Acholi, Somali, Arabic, Farsi, 
Russian, Chinese, Albanian, Bosnian, and 
Vietnamese. FamiUes can learn about 
categorical and income ehgibility standards, 
costs, services, apphcation procedures, and 
civil rights safeguards in those languages. 



The type of language assistance a recipient/covered 
entity provides to ensure meaningful access will 
depend on a variety of factors, including the size 
of the recipient/covered entity, the size of the 
eligible LEP population it serves, the nature of the 



program or service, the objectives of the program, 
the total resources available to the recipient/covered 
entity, the frequency with which particular 
languages are encountered, and the frequency 
with which LEP persons come into contact with 
the program. There is no "one size fits all" solution 
for Title VI comphance with respect to LEP 
persons. The DHHS Office for Civil Rights 
(OCR) will make its assessment of the language 
assistance needed to ensure meaningful access on 
a case by case basis, and a recipient/covered 
entity will have considerable flexibility in 
determining precisely how to fulfill this 
obligation. OCR will focus on the end result - 
whether the recipient/covered entity has taken the 
necessary steps to ensure that LEP persons have 
meaningful access to its programs and services. 

Outstationing. Medicaid law and regulations 
require that States provide an opportunity for 
children under age 19 and pregnant women to 
apply for Medicaid at locations other than local 
TANF offices. States must have such 
"outstationing" arrangements at each facility 
designated as a disproportionate share hospital 
(DSH) and federally qualified health center 
(FQHC) unless there is an approved alternative 
arrangement. Regulafions (42 CFR 435.904) 
permit alternative outstationing arrangements 
under certain limited circumstances; States must 
obtain approval of alternate arrangements through 
a State Plan Amendment. The regulations also 
allow States to establish additional outstation 
sites at other locations where children and 
pregnant women receive services. 



Kentucky: Outstationing Staff 

Kentucky has outstationed staff from all social 
service agencies, including Medicaid, at 
various locations in the community connected 
to middle schools or high schools. In Jefferson 
County (Louisville), each of these locations is 
called a "Neighborhood Place" and offers 
one-stop shopping for residents interested in 
applying for Medicaid and other program 
benefits. 



The initial processing of the Medicaid apphcation 
at outstation sites can be done by individuals 
other than State eligibility staff, such as the 
hospital's or health center's staff. The eligibility 
determination also can be done at the outstation 
site if conducted by State personnel authorized to 
make the determination. States that have expanded 
their outstationing activities have found that 
outstationing helps facilitate enrollment of 
eligible families and children into Medicaid. For 
more information, please see the January 18, 
2001 State Medicaid Director letter. It can be 
found at: 

www.hcfa.gov/Medicaid/smdO 1181 .pdf . 



New York: Facilitated Enrollment 

The New York State Department of Health has 
initiated "facilitated enrollment," a $10 milUon 
program that funds community-based 
coahtions to enroll children in Medicaid and 
SCHIP, known in New York as Child Health 
Plus. The facihtated enroUers help families fill 
out the Growing Up Healthy application (NY's 
joint application for Medicaid and Child 
Health Plus), gather the required documents 
and ensure that the child becomes enrolled. 
The interview with the facilitated enrollers 
counts as face-to-face interview requirement 
for Medicaid purposes. Some of the facilitated 
enrollers also can help explain to families 
how managed care works, help them choose 
a health plan and select a doctor. The 
facilitated enrollers work in community- 
based settings (like schools, day care centers 
and social service agencies) during 
weekdays, evenings and on the weekends. 



Montana: Helping Migrant Workers 

Montana sets up a tent near a cherry 
packing plant where many migrant workers 
are employed during the summer months. 
EligibiUty workers accept and process 
applications on site. The Montana Migrant 
Council brings its mobile clinic and 
provides needed health services on site. 
Other entities, which may include Rural 
Employment Organization, Montana Food 
Bank, Job Service and Migrant Legal 
Services, also are available on site. 



2. Applications: What Else Can Be 
Done? 

Offer a Medicaid-only application and joint 
program applications. There are advantages to 
having both Medicaid-only applications and joint 
program applications. Some States offer a short 
Medicaid-only application to families who do not 
want to apply for other program benefits, such as 
TANF or Food Stamps. A Medicaid-only 
application can be shorter and simpler than a 
joint program application. In addition, some 
States have found that they can dramatically 
shorten the processing time for Medicaid-only 
applications by creating separate, specialized 
administrative units to process these applications. 

Medicaid-only applications typically are used at 
outstationed sites to make Medicaid easily 
accessible to pregnant women and children. To 
reach a wider population, some States use 
Medicaid-only applications at other places in the 
community (e.g., family court, community mental 
health centers, community centers, schools, and 
health fairs). Several States also have developed 
Medicaid-only applications for families as well as 
children and pregnant women and allow families 
to use these forms to apply by mail. 

All States use joint applications so that famihes 
can apply for several programs for which they 



may be eligible. Many families appreciate the 
efficiency of a combined application process. 
While States typically have joint 
Medicaid/FoodStamp/TANF applications and 
most States with separate SCHIP programs have 
joint Medicaid/SCHIP applications for children, 
other joint program applications present 
promising outreach possibilities. Coordinating 
enrollment in Medicaid with enrollment in school 
lunch or Women Infants and Children (WIC) 
programs, for example, provides a good method 
of outreach to the community and can promote 
enrollment among eligible children. Joint 
Medicaid/Food Stamp applications might also be 
a good way to reach low-income working 
families who are not eligible for cash assistance. 



Coordinating Medicaid Outreach 

Coordinating Medicaid outreach with the 
school lunch program can be particularly 
effective in reaching uninsured children. 
Under recent legislation (the Agricultural 
Risk Protection Act of 2000, Pubhc Law 
No. 106-224, H.R. 2559), effective 
October 1, 2000, school food authorities 
can share information from school lunch 
applications with State child health 
agencies for the purpose of identifying 
uninsured children and providing them 
with information about Medicaid and 
SCHIP. To adopt this option, a State must 
have a written agreement assuring that 
shared information will facihtate 
enrollment, and families must be able to 
elect the option not to have the 
information on the school lunch 
application disclosed. 



Joint applications typically are longer than 
Medicaid-only applications and frequently 
involve different program requirements. The 
Medicaid parts of the joint application must 
specify the information pertaining to Medicaid 
eligibihty to ensure that the requirements of other 



programs neither delay the processing of the 
Medicaid application, nor have the effect of 
carrying over other program rules to the 
determination of Medicaid eligibility. 

Shorten and simplify the application. 

Characteristics of a simple application are: 

Clear instructions. Include instructions explaining 
who can apply (e.g., children only or parents 
too), where applicants can get help with the 
application, and how they can submit the form 
(e.g., what to attach, where to mail). 

Omission of all unnecessary questions, clear 
designation of optional items, and explanation of 
reasons for questions. Applications should not 
include questions that are not necessary to 
determine eligibility. It also may be helpful to 
applicants to provide an explanation for optional 
items or reasons for questions. For example, 
several States have found it helpful to explain that 
Medicaid applications ask about already-incurred 
medical bills in order to help famihes pay these 
expenses if they were incurred during the 3- 
month retroactive period. 



Massachusetts Member Benefit 
Brochure 

Families in Massachusetts applying for 
Medicaid and SCHIP benefits receive a 
MassHealth member booklet similar to 
what individuals receive when enrolling in 
private insurance plans. This colorful 
booklet is given out with the MassHealth 
apphcation called the "Medical Benefit 
Request." It describes in plain language: 
how to apply for benefits; provides details 
on who can get benefits, income standards, 
covered services and when coverage 
begins; and it explains other pertinent facts 
such as how to choose a health plan and a 
doctor, out-of-state emergency treatment, 
how to report changes, how the State will 
use the individual's Social Security 
Number and who to call with questions. 



Simple and understandable reading level and 
wording. The reading level and wording on the 
application should be in "plain language" and 
easy to understand. "Writing and Designing Print 
Materials for Beneficiaries" is a guide, which 
CMS issued in 1999, that contains useful 
suggestions for designing Medicaid applications. 
Copies are available from CMS , Office of 
Internal Customer Support, Administrative 
Services Group, SLL-B-15, 7500 Security 
Boulevard, Baltimore, MD, 21244-1850. 

Clear but brief explanation of the applicants' 
rights and responsibilities. States must inform 
applicants and recipients about their rights and 
responsibilities (42 CFR 435.905 (a)(3)). For 
example. States must inform applicants how their 
SSN will be used. However, such information 
does not need to be on the application form unless 
it relates directly to a question asked on the 
application. States can provide information on 
rights and responsibilities in other program 
publications to make the application form 
simpler. If a State wants assurance that the 
applicant is informed, the application form can 
include a signature line attesting that the 
applicant has been given, read and understood 
his/her rights and responsibilities. 

Eliminate face-to-face interviews. Face-to-face 
interviews are not a Federal requirement. 
Families may find it difficult or inconvenient to 
meet face-to-face with an eligibility worker, 
especially families who are employed, live in 
rural areas, or have limited access to transportation. 
Requiring interviews at the local TANF office 
also may raise concerns about the stigma of 
welfare. Some States, as an alternative, have 
eligibility caseworkers visit job sites and homes 
or conduct interviews by phone. When office 
visits are necessary, some States provide 
transportation vouchers, and many arrange 
evening and weekend hours to accommodate 
working families. Most States have dropped the 
interview requirement for children-only 
applications but have not yet taken that step for 
children applying with their families. The 
following are options States have adopted. 



Use phone-in applications. Alternatively, or in 
addition. States can offer telephone interviews. 
Caseworkers can obtain information over the 
phone, complete the application, and mail it to 
the applicant to sign and return, without requiring 
the applicant to obtain and fill out an application 
form or appear for an interview. 

Use mail-in applications. Mail-in applications can 
make it convenient for families to apply and thus 
help ensure that families complete the application 
process. 

Use convenient locations. States may place 
eligibility workers at additional outstationed sites 
beyond those required by Federal law. 
Application assistors who are not eligibility 
workers also can help people apply at various 
sites where potentially eligible families seek 
health care or information. 

Regulations at 42 CFR 435.904(d) specify that 
the agency must provide for the receipt and initial 
processing of Medicaid applications at each 
outstation location. Initial processing means 
taking applications, assisting applicants in 
completing the application, providing information 
and referrals, obtaining required documentation 
and conducting any necessary interviews. 
Therefore, if a State requires a face-to-face 
interview, it must allow for that interview to take 
place at the outstation site. 

Presumptive Eligibility for Children and 
Pregnant Women. Presumptive eligibility 
provides the opportunity to grant immediate 
health care coverage without first requiring a full 
Medicaid eligibility determinafion. This option 
also offers the advantage of providing additional 
"entry points" into the Medicaid program because 
qualified health care providers and other qualified 
entities can grant temporary coverage on the spot 
when children and pregnant women seek health 
care or other services. 

States have the option to provide presumptive 
eligibility for children (under Section 1920A of 
the Social Security Act) and pregnant women 



(under Section 1920 of the Act). At State option, 
entities deemed qualified by the State may 
determine, based on preliminary information 
(e.g., self-declaration), whether the family's 
income is within the State's income limits for 
Medicaid. If so, the child or pregnant woman 
may receive coverage immediately and have until 
the end of the following month to submit a full 
Medicaid application. (The Medicare, Medicaid, 
SCHIP Benefits Improvement Act of 2000 
provides States with the same option under 
SCHIP.) States that have a simplified Medicaid 
application may use this same form to establish 
presumptive eligibility, thereby eliminating the 
need for a two-step application process for 
pregnant women and children. 

Inform the Community. Medicaid eligibility 
rules are not generally well-known to the families 
in the community who are likely to be eligible. 
Indeed, misperceptions about Medicaid abound, 
many originating in the former linkage between 
Medicaid and cash assistance. A widely held 
misbelief is that families must be on "welfare" to 
qualify for Medicaid. Research has shown that 
many parents do not understand that then- 
children, and perhaps they too, may be ehgible 
for Medicaid even though they are not receiving 
cash assistance and/or are employed. Many 
mistakenly believe that TANF provisions, such as 
time limits, apply also to Medicaid. These 
misunderstandings suggest the need for continued 
and more effective outreach efforts that convey 
basic eligibility information to target the 
community, particularly working families. Use of 
appropriate languages and media outlets are 
crucial to the effectiveness of outreach efforts. 

B. Medicaid Eligibility Determination 
Process 

This section outlines Federal rules for determining 
Medicaid eligibility for families and children. 
States must make proper and timely 
determinations, ensure that the actions of other 
programs, such as TANF or Food Stamps, do not 
delay the Medicaid eligibility determination, and 
provide applicants with adequate and clear notice 



of the State's determinations. This section also 
describes some optional policies and procedures 
that States may adopt to improve their efficiency 
and success in boosting participation among 
eligible children and families. 



Eligibility Pilots 

To explore ways to simplify the application 
process and ehminate barriers to 
enrollment, CMS awarded five States with 
grant funds to pilot projects that remove 
barriers in States' apphcation, enrollment, 
and renewal processes. With these funds, 
Florida is piloting a new electronic 
application process targeted at minority 
children served by day care centers. 
Massachusetts is attempting to increase 
retention rates by simphfying its renewal 
process and allowing primary care 
providers to renew a child's coverage when 
the family comes in for care. Ohio and 
Pennsylvania will eliminate income 
verification requirements for some families 
applying for coverage, and Pennsylvania 
will examine further the effect of intensive 
outreach combined with a simplified 
process. Finally, Washington will increase 
its efforts to effectively link children 
receiving school lunch subsidies with 
health care coverage. Results from these 
pilots will be shared with States and other 
interested parties by the end of 2001. 



1. Minimum Eligibility Requirements 

Single State Agency Requirements. Federal law 
(section 1902(a)(5)) and regulafions (42 CFR 
431.10) require that the Medicaid State plan 
designate a single State Medicaid agency to 
administer or supervise the administration of the 
Medicaid program. The plan may designate that 
either the Medicaid agency or the State TANF 
agency make Medicaid eligibility determinations 
for families and individuals under age 21. While 



multiple agencies can assist with the application 
process, the single State Medicaid agency has 
final authority over all Medicaid policies and 
procedures. In addition, the Medicaid agency may 
allow appropriate State eligibility workers at 
outstation locations to make the determinations of 
eligibility if the workers are authorized to 
determine eligibility for the Medicaid agency. 
Federal law (section 1902(a)(55)) and regulations 
(42 CFR 435.904) do allow persons other than 
State employees, however, to perform initial 
processing functions at outstationing sites. 



Working with Immigrant Populations 

Some counties in California have an 
immigrant liaison in their district to address 
concerns specific to immigrants. New 
Mexico (via their Covering Kids 
contractors) entered into an agreement with 
the Immigration and Naturalization 
Services (INS) whereby Medicaid staff 
provides Medicaid training for INS staff, 
and INS does public service 
announcements in Spanish on public charge 
policy to help alleviate immigrant mistrust 
of government agencies. Delaware has 
revised its application form for Medicaid 
and SCHIP to contain a statement that alien 
verification information will not affect any 
public charge determination or lead to 
deportation proceedings. 



Time Standards for Determinations. Federal 
regulations (42 CFR 435.91 1) require that 
Medicaid eligibility for families and children, 
except for those who apply on the basis of 
disability, be determined and proper notice 
provided within 45 days of the date of 
application. Exceptions are allowed for 
circumstances beyond the agency's control, such 
as when the agency cannot reach a decision 
because the applicant or an examining physician 
delays or fails to take a required action. The State 
agency must not use the time standard as a 
waiting period or a reason for denying eligibihty. 



If an individual applies for Medicaid through a 
joint program application (e.g., a Medicaid, Food 
Stamp and TANF application), the State must still 
determine Medicaid eligibility within the Medicaid 
time standard. If processing of the application for 
another program is delayed due to a requirement 
that does not relate to Medicaid, processing of the 
Medicaid portion of the application must continue 
so that a determination is made in a timely manner 
consistent with Medicaid rules. 

Exhaustion of All Avenues of Eligibility. States 
may not deny a completed Medicaid application 
(or terminate coverage) unless it has affirmatively 
explored and exhausted all possible eligibility 
categories. Therefore, States must have effective 
processes in place to consider all possible 
avenues of coverage. The extent to which and the 
manner in which a State must explore other 
possible categories will depend on the 
circumstances of the case, the information 
contained in the application, and the availability 
of other supporting documentation. 

For example, if the application is for a family and 
the State determines the family does not qualify 
under the family coverage category (Section 
1931), it must consider coverage for the children 
in the family under the poverty-level group or 
other children's eligibility groups. If the children 
and the parents do not meet coverage requirements 
for categorically needy family and children's 
groups, and the State has a medically needy 
program, the agency would need to consider 
medically needy coverage for the child and the 
parents. If the application or any other available 
information indicates a member of the family is 
disabled, Medicaid eligibility under the disability 
category must be considered. However, if there is 
no indication of a disability (and the applicant 
has been advised that he or she might qualify for 
Medicaid on the basis of disability), no further 
exploration of eligibility under the disability 
category need be done. 

Basis of Denial. States must base the denial of a 
completed Medicaid application on the failure to 
meet a Medicaid eligibility requirement. States 



10 



may not deny Medicaid eligibility to a family or 
any family member simply because the family is 
ineligible for another program, such as TANF, or 
fails to complete the TANF portion of the 
application process. For example, a requirement 
that TANF applicants submit proof of job contacts 
should not result in the denial of Medicaid. (The 
exception to this rule is that a State may opt in its 
State plan to deny Medicaid to a non-pregnant 
individual adult in the family who does not 
cooperate with the TANF work requirements.) 

Further, States must proceed with the Medicaid 
determination based on the joint application, 
exploring all possible avenues of Medicaid 
eligibility. States are required to dispose of each 
Medicaid application by a finding of eligibility or 
ineligibility unless the applicant either withdraws 
the application or is deceased (42 CFR 435.913). 
Therefore, the agency can not deny the Medicaid 
portion of a joint application based on ineligibility 
for TANF and ask the family to file a new 
application for Medicaid. 

Retroactive Coverage. Federal regulations (42 
CFR 435.914) require States to grant retroactive 
Medicaid benefits for up to three months preceding 
the month of application. States must grant 
Medicaid for any or all months of the retroactive 
period in which the applicant received services 
and would have been eligible for Medicaid if 
application had been made in that month. Under 
retroactive eligibility, Medicaid covers medical 
bills incurred prior to the date of the application. 

Notice of Agency Decision. Federal regulations 
(42 CFR Part 431, Subpart E, and 42 CFR 
435.912) require that States provide notice to 
applicants who are denied Medicaid that informs 
them of the denial, the reasons for it, and their 
appeal rights. Notices must be clear and 
understandable. 

CMS is working with States to develop model 
notice language and is prepared to provide other 
technical assistance to States with regard to 
notices. A State Health Official letter dated 
December 21, 2000 providing more information 



can be found at CMS 's website at: 

www.hcfa.gov/init/chl22100.htm . In addition, CMS 's 
1999 guide, "Writing and Designing Print 
Materials for Beneficiaries," contains useful 
suggestions that could be applied to writing 
notices that beneficiaries can understand. This 
guide is available by requesting copies from 
CMS, Office of Internal Customer Support, 
Administrative Services Group SLL-B-15, 7500 
Security Boulevard, Balfimore, MD 21244-1850. 

2. Eligibility Determinations: What Else Can 
Be Done? 

Accept Other Programs ' Determinations. The 

authority to make Medicaid eligibility 
determinations generally is limited to the State 
Medicaid agency or the State agency administering 
the TANF program. (Title IV-E determinations 
confer automatic Medicaid for IV-E foster care 
children. States also can opt to provide automatic 
Medicaid eligibility to SSI recipients.) The State 
may accept other programs' determinations, 
however, concerning particular eligibility 
requirements provided that the rules for 
determining eligibility with respect to those 
requirements are the same or more restrictive 
than the rules in Medicaid. 

To illustrate, if the resource standard and method 
for determining countable assets under the State's 
TANF program were the same as or more 
restrictive than the rules in the Medicaid program, 
the Medicaid agency can accept the TANF 
agency's determination that a family's assets fall 
below the Medicaid standard without any further 
assessment on its own part regarding this 
requirement. The Medicaid agency would then 
proceed to make a final determination of 
eligibility in light of all remaining eligibility 
requirements. Likewise, if a State's Medicaid 
income standard and method for computing 
income for children is as broad or broader than 
the standard and rules used in the school lunch 
program, the Medicaid agency can rely on the 
school lunch program's determination of income 
to find children income-eligible for Medicaid. 



11 



Effective Date. States have flexibility under the 
Medicaid regulations (42 CFR 435.914) to 
determine the effective date of eligibility. For 
example, a State may grant Medicaid eligibility 
effective as of the date of application or as of the 
first day of the month in which the application 
was submitted. However, the State must ensure 
that retroactive eligibility is provided for up to 
three months preceding the month of application 
to applicants who qualify as discussed above in 
the Retroactive Coverage section. 



Kansas and Michigan: Co-location of 
Eligibility Workers 

A growing number of States that use joint 
applications for children also co-locate 
eligibility workers to expedite 
determinations. In Kansas, State Medicaid 
eligibihty workers and employees of a 
private contractor responsible for 
Health Wave (SCHIP) are housed in one 
location. Famihes seeking health insurance 
for their children complete an application 
and mail it to a central clearinghouse. The 
apphcation is first screened for Medicaid 
eligibihty. State workers make final 
Medicaid eligibihty determinations; private 
contractor employees make final 
HealthWave eligibihty determinations. 
Similarly, in Michigan, applications 
received in the MIChild (SCHIP) office are 
screened for Medicaid by the MIChild 
contractor. If a beneficiary appears to be 
Medicaid-eligible, the application is given 
to the Medicaid-ehgibility worker located 
on-site at the MIChild contractor's office. 
Coverage begins on the day that the 
Medicaid-eligibihty worker determines that 
the child is ehgible. This process eliminates 
delays in determining ehgibility that might 
otherwise occur. 



12 



Chapter II 



MEDICAID RENEWAL AND TERMINATION PROCESSES 



Once families or their children are enrolled 
in Medicaid, States must redetermine or 
"renew" their eligibility at least once a 
year or when a State learns of a change in house- 
hold circumstances that may affect the family's 
eligibility for Medicaid. During a renewal, a State 
must consider all potential eligibility categories 
before it terminates coverage. 

Many States have found that ehgible families 
appear to be losing Medicaid coverage at the 
point when their eligibility is being reviewed; this 
chapter describes some steps States are taking to 
reduce this possibility. Simplified renewal 
procedures will make it easier for ehgible 
families and children to maintain coverage and 
could improve Medicaid participation rates 
among children as well as their families. 

Improved coordination between Medicaid and 
other programs also can be particularly effective 
in ensuring continued Medicaid coverage for 
eligible families and children. For example, 
through improved coordination with the Food 
Stamps and TANF programs, States can ensure 
that they do not terminate Medicaid inappropriately 
due to the requirements of these programs. 
Information from other programs also can help 
States retain eligible children and families. 
During redeterminations, States can rely on 
eligibility information from other programs to 
verify continued Medicaid eligibility and, in fact, 
must rely on any such information that is 
available rather than requiring families to re- 
supply this information. (This internal review of 
eligibility based on available information is called 
an ex parte redetermination.) 

If a State determines that a family is no longer 
eligible for Medicaid, the State should coordinate 
with other coverage programs, particularly 
SCHIP, to make certain that the family or 



children continue to receive health care coverage 
if eligible. This chapter outlines the statutory and 
regulatory requirements and options under 
Medicaid regarding the renewal and termination 
processes. 

A. Maintaining Eligibility During 
Medicaid Redeterminations or 
"Renewals" 

States must periodically review a beneficiary's 
Medicaid eligibility. Within broad Federal 
requirements. States have flexibility to design and 
simphfy their eligibility review procedures, 
which a growing number of States (e.g., 
Connecticut) are calling their renewal procedures. 
The terms "renewal" or "eligibility reviews" are 
used in place of "redetermination" throughout 
this guide. 

1. Minimum Renewal Requirements 

Frequency of Renewals —CMS regulations (42 
CFR 435.916) require States to redetermine 
eligibility at least every 12 months with respect to 
circumstances that may change. (States may use 
longer intervals for reviews of bhndness and 
disability.) 

The regulations also require States to establish 
procedures for timely and accurate reporting of 
any change in circumstances that may impact an 
individual's or family's eligibility (except for 
children if the State has opted to provide 
"continuous eUgibility" as discussed in Chapter 4). 

These minimum requirements are the framework 
in which States design their renewal process. 
However, families often find these and other 
renewal procedures complicated or burdensome 
which can make participation by families 
difficult. For example, some States require face- 



13 



to-face interviews at renewal, require signatures 
on the renewal form, or require that a new 
application be filed even though information 
requests must be limited to circumstances that are 
likely to change and to items the State cannot 
obtain from its existing Medicaid or other 
program files. Medicaid losses result when 
families fail to respond to requests for 
information or to attend an interview. 

Scope of Review of Changes. When a State 
receives a report of changed circumstances, it must 
conduct an eligibility review. The State has the 
option to treat this review of the changed 
circumstances as a full eligibihty review (since 
presumably all other information is unchanged) 
or conduct the full eligibility review at the 
regularly scheduled time. This review of changed 
circumstances constitutes a redetermination for 
purposes of meeting the Federal requirement that 
eligibility be redetermined at least once every 
twelve months. No additional redetermination is 
required until a year from the date that the State 
considered the reported change unless another 
change is reported. 

For example, assume a family applies for 
Medicaid in January and reports an increase in 
income in March. The State finds that the family 
remains eligible despite the increase in income, 
and no further changes are reported. The State is 
not required to redetermine the family's eligibility 
until the following March, one year from the last 
reported change. 

Required Information. Regulations (42 CFR 
435.902 and 435.916) provide that the scope of 
eligibility reviews must be limited to information 
that is necessary to determine ongoing eligibility 
and related to circumstances that are subject to 
change, such as income and residency. States 
may not require families and individuals to 
provide information that: (1) is not relevant to 
their ongoing eligibility; or (2) has already been 
provided and relates to an eligibility factor that is 
not subject to change, such as date of birth or 
United States citizenship. 



Maryland: Automatic Computer 

Updates of Medicaid, TANF and 

Food Stamps 

In Maryland, a redetermination may be 
completed according to schedule (every 6 
months) or due to a change in 
circumstances (including a change in 
circumstances in TANF or Food Stamps). 
Maryland established an electronic data 
base system that interfaces with the TANF, 
Food Stamps and Medicaid programs. 
This interface automatically updates a 
household's changes for Medicaid when a 
change is reported for TANF or Food 
Stamps. When a change is reported, an ex 
parte review for continued Medicaid 
ehgibility is conducted at that time and the 
next regular redetermination is rescheduled 
from the date of the ex parte review. This 
automated coordination of programs 
ensures that case information is current, 
extends Medicaid for the family and 
reduces the number of redeterminations in 
which the family must participate. 



Ex Parte Reviews. States must conduct ex parte 
reviews of ongoing eligibility to the extent 
possible. This means that States must rely on 
information already available to the State before 
contacting the family or individual. States have 
discretion in determining if information from 
sources (other than sources presently relied on 
such as lEVS) is current based on reasonable 
judgment or experience. By relying on available 
information. States can simplify administration 
and avoid unnecessary and repetitive requests to 
families and individuals. They also can reduce the 
risk that an eligible family or individual will not 
complete the renewal process and thus be denied 
continued coverage even when the information 
establishing eligibility is available to the agency. 
However, States are not prohibited by Federal 
regulations from requiring a signed form at an 



14 



annual renewal even if the State has all the 
information it needs to determine eligibility 
during an ex parte review. 

States should use the following sources in 
conducting ex parte reviews: 

Program Records. States must make all reasonable 
efforts to obtain relevant information from 
Medicaid files and other sources (subject to 
confidentiality requirements). State Medicaid 
agencies generally have ready access to Food 
Stamp and TANF records, wage and payment 
information, and information from SSA through 
the SDX or BENDEX systems. They sometimes 
have access to State child care, child support and 
Department of Motor Vehicle files as well. CMS 
issued a State Medicaid Director letter, dated 
June 13, 2000, explaining how States can use the 
information available through the SDX system to 
help them in ex parte reviews. It can be found at 

www.hcfa. gov/Medicaid/SMD6 1 300.htm . 



Food Stamp Eligibility 

In the Food Stamps program, Federal law 
requires States to recertify eUgibihty on a 
regular basis, and individuals receiving 
Food Stamps must promptly report any 
change in their circumstances that would 
affect eligibiUty. Thus, States should 
consider information in Food Stamp 
Program files of individuals currently 
receiving Food Stamp benefits accurate for 
purposes of Medicaid ex parte reviews. 



Family Records. A State must consider records in 
the individual's name, as well as records of 
immediate family members who live with that 
individual, if the State knows the names or has 
other identifying information on these individuals. 
For example, if the State is reviewing a child's 
eUgibiUty for Medicaid and has current information 
about the parent's income in the parent's SSI and 
Medicaid record, the agency must consider and 



rely on that information unless the State has 
reason to beheve it is no longer accurate. In 
accessing and using data from other case records, 
State agencies need to comply with all relevant 
privacy laws and regulations. 

Accuracy of Information. States must rely on 
information that is available and considered to be 
accurate. Information that the State or Federal 
government currently relies on to provide benefits 
under other programs (e.g., TANF, Food Stamps, 
or SSI) should be considered accurate as long as 
those programs require regular redeterminations 
of eligibility and prompt reporting of changes in 
circumstances. 

Obtaining Information from Individuals. If a 
State carmot establish ongoing eligibility through 
an ex parte review, or the ex parte review 
suggests that the individual may no longer be 
eligible for Medicaid, the individual must be 
given a reasonable opportunity to present 
additional or new information before Medicaid is 
terminated. 

Documentation Requirements. As noted above, 
Federal law imposes minimal requirements on 
States with respect to the documentation families 
must supply. The only documentation applicants 
must provide relates to the verification of 
immigration status of qualified aliens. If the 
immigration status has not changed since the 
application was filed, no additional verification is 
required at the time of renewal. 

Allow Families Sufficient Time to Complete the 
Process. Medicaid may not be terminated until 
families and individuals have had sufficient time 
to provide information and complete the renewal 
process. 

2. Renewals: What Else Can Be Done? 

Failure to complete the renewal process has 
emerged as a significant cause of coverage losses 
and non-participation among eligible families and 
children. Many States have been reevaluafing 
their renewal process for Medicaid, identifying 



15 



barriers or problem points, and taking steps to 
remove them. Following are some ways that 
States have simplified the process: 

Drop the Face-to-Face Interview Requirement. 

Federal law does not require interviews. States 
may use a mail-in or phone-in renewal process. 
Face-to-face interviews can be burdensome for 
beneficiaries and agencies and reduce the 
likelihood that families and individuals will 
complete the renewal process. 

Eliminate or Reduce Documentation 
Requirements. States may want to consider 
accepting self-declarations from families with 
respect to changed circumstances. Verification of 
self-declared income is required under the lEVS 
system. For income that cannot be verified under 
lEVS, we encourage random post-eligibility 
verifications or the adoption of other procedures 
designed to assure program integrity is being 
maintained. 

While self-verification clearly makes sense in 
States that accept self-declaration in the initial 
application process, other States that do not rely 
on self-declaration at the application stage may 
want to consider it at the renewal stage. By the 
time of renewal, the State will have been able to 
verify the family's income through lEVS or other 
computer matches. Even if the information 
available through such matches is not current, it 
should be recent enough to allow the State to 
assess whether the individual or family has 
reported information accurately in the past. 

Simplify the Renewal Form. Short, simple 
renewal forms that ask only for information on 
circumstances that may change will promote 
ongoing coverage and help reduce stigma. States 
that use the application form for eligibility 
reviews may have difficulty complying with the 
Federal requirement to obtain information only 
on circumstances that may change. Also, use of 
the application form for renewals may be 
confusing and unnecessarily difficult for 
beneficiaries. 



Use Pre-printed Renewal Forms. States may 
send the family or individual a pre-printed form 
showing current informadon from State files 
concerning circumstances that could change (e.g., 
income), and ask the family or individual to 
indicate whether the informafion has changed. 
States can take at least two approaches with pre- 
printed forms. A State can send the form and 
instruct the family or individual not to send 
anything back if the information is accurate; 
some States call this option "passive renewal." 
Alternatively, a State could require the family or 
individual to sign a confirmation that the 
information is correct and return the form, even if 
there is no change (signatures on renewal forms 
are not required by Federal law). States that rely 
on passive renewal should have some mechanism 
to ensure that the beneficiaries continue to reside 
in the State. Information from the beneficiaries' 
provider or managed care organization that care 
is being provided can provide such assurance. 

Accept Other Programs ' Determinations. In 

addition to accepting other programs' determination 
at the initial point of application. States may 
accept other programs' determinations at renewal. 
For example, if a family has recently been 
approved to receive subsidized child care and the 
income standard and rules for that program are 
the same as or more restrictive than the rules for 
children under Medicaid, the Medicaid agency 
can rely on the child care program's income 
determination when it reviews the child's 
Medicaid eligibility. 

Schedule Reviews Based on Date of Ex Parte 
Review. When a State, in an ex parte review, 
relies on information from another program to 
determine Medicaid eligibility, the State may 
schedule the next regular Medicaid eligibility 
renewal based on the date of this ex parte review, 
or the date of the last review performed by the 
program whose information the State used. 

For example, a family's annual Medicaid renewal 
is scheduled for June 2001. In April 2001, the 
Food Stamps agency determined the family 



16 



continued to be eligible for benefits. In May, the 
Medicaid agency conducted an ex parte review 
based on information from the Food Stamps 
program and determined the family was still 
eligible for Medicaid. The State can choose to 
cancel the upcoming renewal scheduled for June 
2001 and reschedule the family's next annual 
renewal either in April 2002 (12 months from the 
date of the Food Stamps review) or in May 2002 
(12 months from the Medicaid ex parte review). 
Using the later review date will extend the period 
of Medicaid eligibility for the family, and reduce 
administrative burdens on both the family and the 
State agency. 



Washington: Medicaid Review 

For famihes receiving both Medicaid and 
Food Stamps, Washington automatically 
performs a Medicaid review at the time of 
the Food Stamps review and certifies 
twelve new months of Medicaid for those 
who remain eligible. 



Use Outstation Sites for Eligibility Reviews. 

States may rely on outstation sites, including 
disproportionate share hospitals and FQHCs, to 
facilitate eligibility renewals. State personnel at 
these sites can complete the process, and other 
staff or trained volunteers can assist families in 
completing renewal forms and conduct any 
required interviews. 

Adopt "Rolling" Renewals. At least one State 
allows eligibility reviews to be completed 
whenever a family visits a location where such 
reviews are conducted. For example, if a family 
expects to visit an FQHC or a community-based 
organization that assists in Medicaid application 
and enrollment, the State could allow the Medicaid 
renewal process to occur whenever the family had 
reason to visit the FQHC even if the visit 
occurred before the next regularly scheduled 
eligibility review. Using this option, the family 
could complete the Medicaid renewal process at 
the alternative location at the family's convenience 
and avoid a separate contact with the Medicaid 
office. 



Massachusetts: Rolling Renewals 

As noted earUer, CMS has provided grants 
to five States to pilot projects that remove 
barriers in States' apphcation and 
enrollment processes. Massachusetts' pilot 
focuses on simpUfying the renewal process. 
The pilot will create the opportunity for 
famihes to complete the renewal process at 
points of service, such as primary care 
providers' offices, early-childhood service 
providers, or schools, and will allow the 
family to submit the renewal form to 
extend the 12-month period of eligibihty at 
any time during the year. 



Education and Outreach. Putting the renewal 
date on the individual's Medicaid card can serve 
as a helpful reminder to beneficiaries. It is 
essential that families and individuals know that 
their eligibility will be reviewed periodically, 
what the process will be, when it will occur, and 
why it is important to complete the process if 
they are asked for information. Some States are 
sending more than one notice to alert families to 
the need for renewal. 

Education can occur at the time of application, 
through written materials provided prior to the 
renewal, through community-based organizations, 
and other strategies. It also is important to use 
program names that beneficiaries will recognize 
when renewal forms are sent to them. Since the 
beneficiary's enrollment cards may be issued by 
their managed care organization, renewal forms 
might need to identify the managed care 
organization to help beneficiaries realize that they 
must respond to the Medicaid agency's request 
for renewal information. 

In addition, providers can help alert families to 
the renewal requirements. Managed care plans, 
for example, have an interest in retaining current 
enrollees and may be able to supplement the 
Medicaid agency's efforts to inform families of 
the renewal obligations. 



17 



Follow Up with Families that Fail to Complete 
the Process. It is a good practice to give families 
and individuals more than one opportunity to 
provide information needed to complete the 
renewal process. Several States have developed a 
process that follows up on non-responses through 
written reminders, phone calls, or personal 
contact. A summary of follow-up activities 
undertaken by States in SCHIP (including 
Medicaid expansions) is included in Mathematica 
Policy Research's January 2001 report titled 
"Implementation of the State Children's Health 
Insurance Program: Momentum Is Increasing 
After a Modest Start." It is available at 
http://www.mathematica-mpr.com/pdfs/schipl.pdf. 
States may enlist the support of community-based 
organizations and other groups to assist in follow- 
up. For example. States that rely on "application 
assistors" to help enroll children are considering 
ways to involve them in the renewal process. 



Illinois: Personal Notes 

The Livingston County Office in Illinois 
sends follow-up letters to their beneficiaries 
that supplement letters generated by the 
State's computer system. The language in 
the letters explains exactly what the family 
must do to maintain assistance. The 
personal notes are sent to beneficiaries by 
the caseworkers to remind them of 
redeterminations, or to explain terminations 
or denials and to suggest they call the local 
office if they have questions. 



B. Medicaid Eligibility Termination 
Process 

States must ensure that termination from Medicaid 
occurs only after a determination that the family 
or individual is not eligible under any category of 
coverage, or after the individual or family fails to 
complete the renewal process after receiving a 
reasonable opportunity to do so. 



Minimum Termination Requirements 

Basis of Termination. A State must terminate 
Medicaid eligibility if it has made a determination 
that the individual is no longer eligible under any 
eligibility category. A State may not terminate 
Medicaid eligibility based on requirements that 
relate to other programs, such as TANF and Food 
Stamps, but that do not directly affect Medicaid 
eligibility, except for a non-pregnant adult in the 
family who fails to meet the TANF work 
requirements if a State has elected this option in 
its State plan. 

Exhaust All Possible Avenues of Coverage. 

Similar to the rules relating to initial eligibility 
determinations, States may not terminate Medicaid 
eligibility unless they have affirmatively explored 
and exhausted all possible avenues to Medicaid 
eligibility. States may not determine eligibility for 
some categories and require families to reapply in 
order to determine eligibility for other categories. 

States must have processes in place that explore 
and exhaust all possible avenues of eligibility. 
These processes must first consider whether the 
family or individual continues to be eligible 
under the current category of eligibility and, if 
not, explore eligibility under other possible 
categories. 

The extent to which and the manner in which a 
State must explore other possible categories will 
depend on the circumstances of the case and the 
information available to the State. For example, if 
the State has information in its Medicaid files (or 
other available program files) suggesting an 
individual is no longer eligible under the poverty- 
level category but potentially may be eligible on 
some other basis (e.g., on the basis of disability 
or pregnancy), the State must consider eligibility 
under that category on an ex parte basis without 
requiring the family to reapply. 

If the ex parte review (i.e., a review based on 
information available to the State) does not 
establish eligibility under any category, the State 
must provide the family or individual a 



18 



reasonable opportunity to provide information to 
establish the potential bases for ongoing Medicaid 
eligibility, including disability or pregnancy. A 
State does not have to maintain coverage unless 
the individual has provided some reasonable 
indication that he or she may be eligible under 
some other basis. 

Since Medicaid has many eligibility categories, 
some States have developed computer systems 
that automatically explore all the various possible 
eligibility categories. In the absence of such 
systems, it is particularly important to have 
ongoing State training and institutionalized 
methods to ensure that the policy to consider 
alternative eligibility categories before terminating 
coverage is implemented properly. 

In States with separate SCHIP programs, children 
who become ineligible for Medicaid due to excess 
income are likely to be eligible for coverage in 
SCHIP. Under Federal law. States must coordinate 
Medicaid and SCHIP coverage. States should 
develop methods for ensuring that these children 
are evaluated and enrolled in SCHIP, as 
appropriate. 

Medicaid Termination Notices and Appeal 
Rights. CMS regulations (42 CFR, Part 431, 
Subpart E, and 42 CFR 435.912) require that 
individuals who are terminated from Medicaid 
receive timely notices informing them of the 
termination, the reasons for the termination, and 
their appeal rights. With very few exceptions 
Medicaid coverage for current beneficiaries 
continues during an appeal that is requested in a 
timely manner. States must give at least 10 days 
advance written notice of its intention to terminate 
eligibility. 

Transitional Medical Assistance (TMA). When a 
family loses eligibility for Medicaid under the 
Section 1931 group because of earned income 
and has received Medicaid under that group in 3 
of the preceding 6 months, the family is entitled 
to transitional medical assistance (TMA), which 
also is known as extended Medicaid benefits or 
transitional benefits, for 12 months. (In order to 



be eligible for TMA in the second 6 months, the 
family must file certain reports and the family's 
earned income, minus the cost of child care, must 
not exceed 1 85 percent of the Federal poverty 
level.) TMA is no longer tied to prior receipt of 
cash or loss of cash but is related only to 
eligibility for Medicaid under the 1931 group. 
Therefore, the receipt or loss of TANF has no 
bearing on TMA eligibility. 

TMA is like any other eligibility category — 
States may not terminate individuals from 
Medicaid at the end of the transitional Medicaid 
period without first conducting an eligibility 
review, including an ex-parte review. Coverage 
must be continued if any individual in the family 
is eligible under an alternate eligibility category. 

Moves Within the State. A State plan for 
Medicaid must provide that it shall be in effect 
statewide (section 1902(a)(1)). This means that 
the State plan must be in effect statewide and all 
counties within the State must comply with the 
State plan provisions. 

It also means when a family moves within the 
State even in a State with a county-administered 
Medicaid program, the State and the counties are 
responsible for transferring the case record from 
the old county of residence to the new county of 
residence so that Medicaid can continue without 
interruption. The State cannot require the family 
to reapply for Medicaid or have its Medicaid 
eligibility reviewed solely based upon a move to 
a new county. An eligibility review may be 
appropriate if there are changed circumstances 
that might affect eligibility; for example, if the 
family moved because a parent obtained a new job. 



19 



Chapter III 



TANF/MEDICAID DELINKING 



This chapter focuses on ways States can 
improve Medicaid coordination with the 
TANF program and effectively dehnk 
Medicaid and TANF. It covers mandatory and 
optional policies discussed above, as applied to 
the Medicaid/TANF context. It draws on the 
findings from the 50 State Medicaid/TANF 
reviews and identifies practices States are 
employing to dehnk Medicaid and TANF more 
effectively. 

With the end of the automatic link between 
Medicaid and TANF eligibility, many States are 
working to improve the coordination between the 
TANF and Medicaid programs and are 
simplifying Medicaid enrollment at TANF 
offices. TANF offices can be instrumental in 
ensuring that eligible families get enrolled in 
Medicaid and SCHIP even if famihes are not 
eligible for TANF or do not want TANF. At the 
same time, poor coordination between the TANF 
and Medicaid agencies can create barriers to 
Medicaid enrollment and contribute to dechnes in 
coverage among Medicaid-eligible families. 

A. Application and Enrollment 

Enhanced Federal Matching Payments for 
Delinking Activities. As set forth in State 
Medicaid Director letters dated May 14, 1997 
and January 6, 2000, Congress established a $500 
million fund to help States make appropriate 
modifications in their Medicaid program enroll- 
ment and eligibility determination processes in 
light of welfare reform. Federal funding is 
available at an enhanced match rate for computer 
modifications and other activities related to 
implementation of welfare reform. As of March 
2001, many States have not yet used their full 
allotments under this fund. We encourage States 
to review the expenditures of their allotments and 
to access any funds that might still be available to 



make necessary changes related to delinking in 
their integrated eligibility systems. For example, 
in the context of dehnking, these funds can be 
used to pay for: 

• Upgrades to automated eUgibihty determination 
systems; 

• New notices and brochures that explain 
dehnking to families; 

• Staff training; and 

• Outreach to families and children. 

Ensure the Opportunity to Apply for Medicaid 
in TANF Offices. Medicaid regulations (42 CFR 
435.906) require States to provide famihes the 
opportunity to apply for Medicaid without delay. 
When States use joint program apphcations or 
use the State TANF agency to make Medicaid 
eligibility determinations, their TANF offices also 
serve as their Medicaid offices. These offices 
must furnish an application (either a joint 
application or a separate Medicaid apphcation, as 
appropriate) immediately upon request. They may 
not impose a waiting period in order to conform 
their Medicaid determinations to TANF policy or 
procedural requirements. Also, they may not ask 
apphcants to wait to apply for Medicaid until 
they meet such TANF eligibility conditions as job 
training or job search. Finally, States may not 
require individuals applying for Medicaid at the 
TANF office to repeat any aspect of the joint 
apphcation process, such as the interview, at the 
Medicaid office in order to complete the Medicaid 
application. 

Many States encourage individuals to apply for 
all assistance programs for which they are ehgible. 
While this approach has many advantages, it must 
be implemented in a way that does not discourage 
individuals from applying just for Medicaid. If an 
individual is not ehgible for other program 
benefits or decides not to apply for another 



21 



program (for example, after receiving a full 
explanation of TANF program requirements), the 
State must advise the individual at that time that 
he or she may apply for Medicaid and allow the 
individual to apply without delay. 



Eligibility Worker Training 

Iowa has a help desk for income 
maintenance workers with questions and 
answers on policy and systems available to 
them at their desk. The help desk plans to 
have an internet or intranet site for 
frequently asked questions that income 
maintenance workers would access from 
their desktops. Other States provide 
ongoing training that engages worker 
attention and participation by offering 
refresher quizzes (Missouri), board games 
focusing on eligibility issues 
(Massachusetts), and an on-hne interactive 
training session (Utah). 



Make the Process Simple. States using a joint 
TANF/Medicaid application must make sure that 
the TANF application process does not present 
barriers to applying for Medicaid. States are using 
different approaches to eliminate such barriers: 

States can structure a joint application form so 
that the basic form incorporates only the 
fundamental information applicable to all programs 
and then attach short, simple supplemental forms 
for each of the programs. In this way, applicants 
provide information common to all programs and 
complete only the forms for the specific program 
benefits they are seeking. 

Alternatively, States can develop a joint appUcation 
that identifies which portion(s) of the application 
need to be completed for each of the programs 
for which the application is being used. 

States must clearly identify the documentation 
requirements of the different programs. For 
example, if TANF requires proof of assets, but 
Medicaid does not, the form (or the document 



listing required verification) should so indicate so 
that applicants know what information they must 
provide for each program. Making the forms and 
application packages clear in this way also will 
help to remind eligibility workers of the different 
program rules. 

States may use a Medicaid-only application or a 
Medicaid/Food Stamp application for families 
who do not want TANF. A Medicaid-only 
application is often shorter and easier to complete 
than a joint TANF/Medicaid application and 
relieves the family from furnishing information 
not relevant to the benefits they wish to receive. 

Ensure TANF Caseworkers Understand 
Medicaid Rules and Processes. TANF agency 
staff who are determining Medicaid eligibility 
must be fully informed of Medicaid eligibility 
rules. Staff training, supervisor sign-off on 
Medicaid denials (and terminations), and other 
mechanisms help send the message that the rules 
for Medicaid are different than the TANF rules 
and ensure that workers apply Medicaid rules 
properly. 

TANF caseworkers often are the families' primary 
source of information on public benefits, including 
Medicaid. Thus, workers must be able to impart 
information about Medicaid accurately. It is 
important to inform families early in the 
application process that even if they don't qualify 
for TANF, their application for Medicaid could 
well be approved. Families receiving TANF also 
need information about how employment and 
time limits will or will not affect their Medicaid 
eligibility. A study released in January 2000 by 
the Kaiser Commission on Medicaid and the 
Uninsured shows that most families thought that 
time limits applied to Medicaid as well as TANF. 
The Southern Institute on Children and Families 
has prepared State-specific brochures for 13 
States describing the range of benefits, including 
Medicaid, that working families can receive even 
if they are no longer eligible for TANF. For more 
information on these brochures, contact the 
Southern Institute at (803) 779-2607 or check 
their website at www.kidsouth.org. 



22 



B. Determining Eligibility for TANF 
and Medicaid 

Timely Medicaid Determinations. Federal rules 
that require Medicaid eligibility to be determined 
within 45 days apply to joint Medicaid/TANF 
applications. A TANF requirement may not 
substantially delay a Medicaid eligibility 
determination. For example, when a family 
applies for Medicaid and TANF through a joint 
application, but needs to meet certain TANF 
requirements before establishing TANF eligibility 
(e.g., make a certain number of job search 
contacts), the TANF requirements should not 
result in a delay in the processing of the 
Medicaid application. The State must make a 
timely determination of Medicaid eligibility based 
on the joint application. 

Delink eligibility determinations. States can 
"delink" the processing of joint applications by 
forwarding the Medicaid information to a Medicaid 
processing system that also handles Medicaid- 
only applications for families. Some States have 
adopted this option and found that it ensures the 
proper processing of all Medicaid applications, 
including those for families who are denied 
TANF. It also can dramatically shorten the 
timeframe for making Medicaid eligibility 
determinations. 

C. TANF Denials and Terminations: 
Effects on Medicaid 

Proper Medicaid Denials and Terminations. 

Since Medicaid eligibility is not tied to TANF 
eligibility. States may not delay, deny, or terminate 
Medicaid to a family or any family member 
simply because the family is ineligible for TANF 
(e.g., due to employment, time limits, sanctions 
or any other reason). (The one exception is that 
States may opt in their Medicaid State plan to 
terminate Medicaid for a non-pregnant adult in 
the family who loses TANF due to a failure to 
comply with the TANF work requirements.) 
Further, States cannot deny joint applications 
based on the TANF denials and then advise 



families to reapply for Medicaid if they think 
they may be eligible. 

As noted earlier. States are prohibited from 
denying or terminating Medicaid eligibility 
unless they have explored and exhausted all other 
avenues to Medicaid eligibihty. Medicaid 
generally covers a broader group of children and 
famihes than may be eligible for TANF. Thus, 
some or all members of a family who are 
ineligible for TANF are likely to be eligible for 
Medicaid. There are a number of possible 
avenues to Medicaid for family members denied 
or terminated from TANF, including the family 
coverage (Section 1931) category, poverty level 
groups and transitional medical assistance. 

Notices. States must give written notice to 
individuals denied or terminated from Medicaid 
informing them of the reason for the action and 
of their appeal rights. Since many families 
beUeve that TANF and Medicaid are linked, they 
may assume that Medicaid is denied or terminated 
when TANF is lost. Therefore, it is important that 
notices regarding TANF denials and terminations 
convey clearly that the TANF action does not 
necessarily mean that the family is ineligible for 
Medicaid. If the family is not currently enrolled in 
Medicaid or does not have a Medicaid application 
pending, the TANF notice should advise the family 
how to apply for Medicaid benefits. 

The following are some strategies States may use 
to ensure that TANF denials and terminations do 
not adversely impact Medicaid. 

• Checklists. In Durham County, North 

Carolina, the local Medicaid agency staff use 
an "at a glance" checklist to cross reference 
TANF closure codes against potential 
Medicaid eligibihty categories. The checklist 
includes the possible options for continuing 
Medicaid coverage (e.g., 12-month continuous 
coverage and transitional Medicaid), lists the 
steps to estabhsh this coverage, and requires a 
certification with caseworker signature, as well 
as the date and result of the Medicaid 
redetermination. 



23 



• Second-Party Case Reviews. States may 
establish second and third-party reviews of 
TANF/Medicaid denied and terminated cases 
to ensure that Medicaid is not inappropriately 
lost when TANF is denied or terminated. Some 
States use a multi-layer process of case reviews 
conducted by district, county and State 
supervisors. Tennessee uses independent 
contracted staff to perform third-party reviews 
of closed or denied TANF cases before taking 
negative actions. These contractors also explain 
to families what additional opportunities for 
coverage are available. 

• Computer Blocks. States may use computer 
blocks or other methods to ensure that 
Medicaid eligibility is not erroneously lost 
when TANF is denied or terminated. Maryland 
has placed a computer block on all TANF 
work-related terminations and denials. This 
block remains in place until cases have 
undergone second and third-party reviews to 
ensure that Medicaid eligibility is not 
improperly lost. North Carolina has conducted 
systems queries to identify terminated TANF 
cases that have not been reviewed for Medicaid 
eligibility. 

D. Computer Systems 

As Medicaid eligibility is complex, States have 
found computer-based eligibility determination 
systems to be critical to making accurate 
eligibility decisions. There is considerable 
evidence that manual systems, or computer-based 
systems that rely heavily on manual intervention, 
are much more prone to error than updated, fully- 
automated systems. 

Delinking of Computer Systems. Automated 
eligibility systems play a critical role in assuring 
that States make proper eligibility determinations. 
States have an obligation under Federal law to 
ensure that their computer systems are not 
improperly denying enrollment in, or terminating 
persons from, Medicaid. A major finding that 
emerged from the DHHS Medicaid/TANF 



dehnking reviews is that, at the time, many States 
had not reprogrammed their computer eligibility 
systems to delink Medicaid from cash assistance. 

Implementation of Interim Back-up Processes. 

In a State Medicaid Director letter dated April 7, 
2000, CMS directed States to review and, if 
necessary, correct their computer systems in order 
to reflect current Medicaid eligibility rules. 
States are under an obligation to take immediate 
action to correct any identified computer 
eligibility systems problems. If States cannot 
make programming changes immediately, they 
must institute an interim system that overrides 
computer errors and ensures that Medicaid is not 
being denied or terminated improperly. 

CMS has identified a number of approaches 
adopted by some States to prevent erroneous 
computer actions. In each case, the State adopted 
a formal and systematic approach to identifying 
and correcting computer-based errors until such 
time that reprogramming could occur. A simple 
instruction to workers to override or work around 
computer errors is insufficient to ensure that 
erroneous denials and terminations will not occur. 
The back-up approaches States have used are 
listed below. 

• Supervisory Review - Supervisors review all 
TANF denials or case closures before any 
Medicaid denials or terminations proceed. 
Having trained supervisors review denials and 
terminations can help prevent wrongful actions 
from occurring. 

• Centralized Review - Local supervisors and a 
State-level task force review all Medicaid 
denials and terminations that coincide with a 
TANF denial or termination. 

• "Preemptory" reinstatement - Caseworkers and 
managers give cases scheduled for termination 
"next-day" audits. Cases that continue to be 
eligible for Medicaid are "reinstated" before the 
scheduled Medicaid closure. 



24 



Medicaid Management Information Systems 
(MMIS). Most States have an automated claims 
processing and information retrieval system 
(commonly known as MMIS). In addition to 
assuring that computer eligibility systems are 
properly programmed to reflect ongoing 
Medicaid regardless of eligibility for TANF, 
States may be able to take advantage of the 
already existing interface between their MMIS 
and their integrated eligibility systems (lES). 
Currently, most lES transmit data daily to an 
MMIS. This data transmission is necessary to 
assure that the MMIS is operating from the most 
current eligibility decisions. 

States may want to program their MMIS to "talk 
back" to their integrated eligibility system to 
disallow improper terminations. Alternatively, a 
similar but simpler approach is to program a 
block of MMIS closures until a supervisor reviews 
the cases in question. For example, a State could 
select TANF closing codes (excepting out certain 
closures, e.g., death and loss of residency) and 
apply a block to automated MMIS closures in 
cases that have the selected TANF closing codes. 
The MMIS system could be programmed to 
produce a daily report of blocked closures. After 
a central or supervisory review of the blocked 
closures, the State could manually enter the 
confirmed closures into the MMIS system. 
Periodic reconciliation of an lES and a MMIS 
would assure that accuracy and consistency are 
maintained. 

MMIS enhanced Federal funding may be 
available for changes to MMIS. We encourage 
States to consult with their regional offices about 
the availability of enhanced funding. 

Systems Automation. An additional finding from 
the TANF/Medicaid reviews was that there is 
wide variation among States as to the degree of 
modernization and automation of integrated 
eligibility systems. The number of eUgibility 
categories has grown over the last several years. 
Each category has a set of complex rules and 
many options, and States need to exhaust all 



categories of possible eligibility before denying or 
terminating Medicaid. Computer systems can 
more effectively and efficiently manage these 
complexities than manual procedures. A manual 
determination process, or a process that requires 
manual intervention by the caseworker, is much 
more likely to be error prone and to create 
problems for apphcants, beneficiaries and the 
agency. 



25 



Chapter IV 



MEDICAID ELIGIBILITY EXPANSIONS AND POLICIES 



A. Minimum Requirements 

Enactment of the Personal Responsibility and 
Work Opportunity Reconciliation Act of 1996 
(PRWORA) delinked eligibility for Medicaid 
from receipt of cash assistance and established a 
new Medicaid eligibility category for low-income 
famihes. Under Section 1931 of the Social Security 
Act, States must provide Medicaid to families 
with children who meet the eligibility criteria 
regardless of whether or not they are eligible for 
or receive TANF cash assistance. 

Section 1902(a)(17) of the Social Security Act 
requires States to establish eligibility standards 
for a given Medicaid group that are the same for 
all members of that group. This means that, 
generally, the eligibility rules must be the same 
for all Medicaid applicants and recipients within 
the Section 1931 group. 

Under Section 1931, States have numerous 
options that allow them to cover additional 
families and/or simphfy eligibihty requirements 
and administration. 



Using Section 1931 flexibility, a 
number of States: 

• Disregard all resources; 

• Disregard a car of any value; 

• Disregard the cash value of life 
insurance; 

• Disregard the actual cost of child care; 

• Disregard more income than required; 
and, 

• Eliminate the time hmits on the 
earned income disregards. 



Additional Resources 

The National Governors' Association (NGA) 
has released two Issue Briefs on State policy 
options for extending health care coverage 
to low-income families. "State Policy 
Options for Health Care Coverage for 
Families On, Leaving, or Diverted from 
Welfare and Other Low-Income Families" 
provides options for States to ensure that 
current welfare recipients, former welfare 
recipients and those diverted from welfare 
have access to health care coverage. It also 
discusses options for extending coverage to 
low-income families that may never have 
received cash assistance. A companion Issue 
Brief, "State Outreach and Enrollment 
Strategies to Improve Low-Income FamiUes' 
Access to Medicaid," focuses on State best 
practices to enhance Medicaid coverage 
such as expanding outreach efforts, updating 
automated eligibility systems and 
simphfying eligibility determination and 
redetermination processes. These Issue 
Briefs can be found on NGAs website at: 

www.nga.org/Pubs/IssueBriefs/2000/Sum0009 1 5Low 
income.asp 

and 

www.nga.org/Pubs/IssueBriefs/2000/Sum0009 1 5TAN 
Rasp. 



27 



B. Policies and Expansions: What Else 
Can Be Done? 

Less Restrictive Policies under Section 1931. 

States have significant flexibility in establishing 
Medicaid eligibility for low-income families 
under Section 1931. 

First, States have the option to raise their income 
standard by the percentage increases in the urban 
component of the CPI since the enactment of 
PRWORA. This provision allows additional 
families to become eligible under Section 1931. 
If a State chooses to raise its income standard for 
the Section 1931 group, it may raise the 
medically needy standard accordingly. This 
change would allow additional families to become 
eligible as medically needy through a spenddown. 



District of Columbia: Gross 
Income Test 

The District of Columbia now basically 
uses a gross income test of 200 percent of 
the FPL for families with children under 
19 years of age. Child care expenses and 
income excluded under other Federal 
statutes are the only allowable income 
deductions. To accomplish this, the 
District disregards income in the amount 
of the difference between its AFDC 
standard in effect on July 16, 1996 and 
200 percent of the FPL plus the cost of 
child care necessary for someone to work. 
This was done through a State plan 
amendment (no waiver needed). The 
District receives SCHIP enhanced 
matching funds for the children (but not 
adults) in the expansion group. 



Second, States have the option to adopt methods 
of determining countable income and resources 
that are less restrictive than those used under the 
State's AFDC State plan in effect on July 16, 1996. 
States may take advantage of this flexibility to 



simplify family eligibility by disregarding certain 
types of income that AFDC counted. For example, 
they could disregard income that was irregular or 
incidental, such as interest income. States also 
may cover additional families, who would not be 
ehgible using the July 16, 1996 policies, by 
disregarding additional income and/or resources. 



Less Restrictive Methods 

As of December 2000, Maine, New Jersey, 
Connecticut, Ohio, California, Rhode 
Island and Washington, D.C. use less 
restrictive methods to determine eligibility 
under Section 1931. Missouri, Wisconsin 
and New York have waivers to implement 
more liberal methods. Several other States 
are considering using more liberal methods 
including Louisiana and Indiana. 



While States must carry out a prompt renewal of 
eligibility when they learn of changes in 
circumstances, they can use less restrictive 
methodologies under Sections 1902(r)(2) and 
1931 to disregard small fluctuations in income. 
For example, a State can choose to disregard 
increases in income of less than $100 until the next 
regularly scheduled redetermination or until a 
redetermination is triggered by some change other 
than an increase in income. If a State chooses to do 
this, individuals would not be required to report 
increases in income of less than $100 above the 
amount reported at application or redetermination 
until the next redetermination. This both eases the 
reporting burden on the family and simplifies 
administration for the State. 

Furthermore, States may use this "less restrictive 
method" to effectively raise the income standard 
to any level chosen by the State. For example, a 
State could disregard the difference between the 
July 16, 1996, AFDC standard and 200 percent of 
the Federal poverty level (FPL), effectively raising 
the income standard for families with children to 
200 percent FPL. 

If a State expands eligibility of the Section 1931 



28 



group after March 31, 1997, enhanced Federal 
matching funds at the SCHIP rate are available 
for children without insurance who would not 
have been eligible for Medicaid in absence of the 
expansion. 

Converting to a Gross Income Standard. States 
also may use less restrictive methods to eliminate 
the 185-percent gross income test that existed 
under AFDC on July 16, 1996 and that otherwise 
continues to apply to Medicaid under Section 
1931. (Generally, under AFDC there were two 
income tests. The first test was whether a family's 
gross income was at or above 1 85 percent of the 
State's AFDC "need standard." If gross income 
was at or above 1 85 percent of the need standard, 
the family was ineligible and there was no need 
to apply the second test. If the family's gross 
income was less than 1 85 percent of the State's 
need standard, the State determined countable 
income by applying income disregards and 
comparing countable income to the AFDC 
payment standard. To be eUgible, the family's 
income after application of the disregards had to 
be below the payment/need standard.) 
Alternatively, a State may combine the 1 85 
percent gross income test and less restrictive 
methodologies to establish a simpler gross income 
test. 

Eliminating the "100-hour" Rule. 

States now have the option to provide Medicaid 
eligibility to all families, including two-parent 
families in which the principal wage earner works 
fuU time. Under Section 1931, States must provide 
Medicaid eligibility to a family with a child who 
is deprived by the absence, death, incapacity or 
unemployment of a parent and has income and 
resources below the old AFDC standards. By 
regulation, the AFDC program defined 
unemployment as working less than 100 hours 
per month. Thus, a two-parent family in which 
the principal wage earner worked full time could 
not qualify for AFDC except under very limited 
circumstances. Prior to PRWORA, many States 
had been granted a waiver of the 100-hour rule as 
part of a welfare reform demonstration project. 
Section 1931 allowed States to continue waivers 



Gross Income: Another Approach 

One State is considering converting its 
Section 1931 income standard to a gross 
income standard. It would do this by 
disregarding income in the amount of the 
difference between 185 percent of the 
AFDC standard in effect on July 16, 1996, 
and 1 85 percent of the Federal poverty 
level for purposes of the 185 percent gross 
income test. As a result, any family with 
gross income below 185 percent of the 
poverty level passes the first income test. 
The State would then effectively eUminate 
the second income test by disregarding all 
income for purposes of that test. As a 
result, aU famihes with gross income below 
185 percent of the poverty level will be 
eUgible. The State could adopt this policy 
through a Medicaid State plan amendment. 



of Part A of title IV that were in effect on July 
16, 1996. Most States opted to continue the 
waivers of the 100-hour rule. 

On August 7, 1998, DHHS revised the old AFDC 
rules to allow States to define unemployment 
(Federal Register / Vol. 63, No. 152 / pages 
42270-4). States now can, without a waiver, define 
unemployment in such a manner that they can 
cover two-parent famihes in which a parent works 
full time. All States now have the option to 
effectively determine the Medicaid eligibihty of a 
two-parent family on the basis of income and 
resources. 

Options for Children and Pregnant Women 
Coverage. Section 1902(r)(2) apphes to most 
Medicaid ehgibihty groups for children and 
pregnant women. It provides States with the same 
flexibility described under Section 1931 
discussed above. That is, the State may choose to 
disregard income and/or resources that otherwise 
would be counted under Federal rules. 
If a State uses the 1902(r)(2) authority to expand 



29 



eligibility after March 31, 1997, enhanced Federal 
matching funds at the SCRIP rate are available for 
children without insurance who would not have 
been eligible for Medicaid in absence of the 
expansion. 

Simplifying Eligibility Determinations by 
Merging Eligibility Groups. States may use the 
flexibility explained above to effectively eliminate 
the differences in the eligibility standards and 
methodologies used to determine the eligibility of 
all low-income families, children and pregnant 
women. States can have one set of financial 
eligibility rules (e.g., disregards and exemptions) 
for all of its Medicaid categories relating to 
families and children. 

Continuous Eligibility for Children. Under a 
provision of law enacted in 1997, States may 
choose to provide Medicaid to children under age 
19 for a continuous period of up to 12 months. 
Once a State determines that a child is eligible, the 
child remains eligible for the period of continuous 
ehgibility chosen by the State regardless of changes 
in the child's circumstances (other than reaching 
age 19 or moving out of State). If a State chooses 
this option, continuous eligibility applies to all 
children found eligible for Medicaid regardless of 
the basis of eligibility. For example, if a State 
adopts the continuous ehgibility option, continuous 
coverage must be provided to children in the 
Section 1931 family category as well as to the 
poverty-level children. 

States have asked what can be done when an 
additional child in the family becomes eligible 
for Medicaid to avoid different periods of 
continuous eligibility in the same family. At the 
same time that the additional child is determined 
eligible, the State can redetermine the eligibility 
of the children already receiving Medicaid and 
begin a new period of continuous eligibility for 
them so that all children in the family will have 
the same period of continuous eligibility. If the 
State determines at the redetermination that the 
children are no longer eligible, however, the State 
must continue to provide Medicaid until the end 
of the original period of continuous eligibility. 



Ensuring Access to Transitional Medical 
Assistance (TMA). In many circumstances, 
families find employment and lose eligibility 
under the Section 1931 group after one or two 
months. These famihes are not entitled to TMA 
because they did not receive Medicaid under the 
Section 1931 group in three of the preceding six 
months. However, States may use the flexibility 
available under the "less restrictive methods" 
provision to enable these families to qualify for 
TMA. To do this, the State would exclude all 
earned income in the first 3 months of eligibility 
once eligibility under the Section 1931 group is 
established. (Earned income disregards constitute 
the sole exception to the rule that States must 
treat applicants and recipients comparably; that 
is. States can apply these disregards to recipients 
only. This is because the AFDC rules that 
underlie Section 1931 eligibility allowed AFDC 
applicants and recipients to be treated differently 
in this respect.) This 3 -month disregard allows 
the family to remain eligible under Section 1931 
for 3 months regardless of earnings. At the end of 
the third month, the earnings will count, and the 
family will be eligible for 6 or 12 months of 
TMA. A State may implement this policy through 
a State plan amendment. 



Nevada: Transitional Medicaid 

Nevada uses a 100 percent earned income 
disregard for three months and a 50 percent 
earned income disregard for the next nine 
months as well as disregarding the full cost 
of child care. The three month 100 percent 
earned income disregard makes it easier for 
famihes to receive transitional Medicaid by 
facilitating the requirement that Medicaid 
must be received in three of the six months 
prior to losing Medicaid under Section 
1931 because of earnings. 



Extending Transitional Medical Assistance 

(TMA). Some States have chosen to provide TMA 
for more than 12 months when someone finds 
employment that would otherwise make the family 
ineligible for Medicaid under the Section 1931 



30 



group. As families work towards self-sufficiency, 
they often begin in jobs that do not offer health 
insurance or do not pay sufficient wages for the 
family to afford the premiums and other costs 
associated with most private health insurance or 
the employer health insurance package may not 
include services provided under Medicaid. An 
additional period of Medicaid eligibility may 
allow the family to raise the level of their 
employment before losing Medicaid or it may 
provide coverage until the point that it becomes 
available through the work place. 

Technically, States may not provide TMA for 
longer than 12 months. However, States may use 
the flexibility under Section 1931 to provide 
more than 12 months of additional Medicaid 
benefits to almost all families that would 
otherwise lose eligibility under the Section 1931 
group because of earnings. For example, to 
provide 24 months of additional Medicaid, a 
State would exclude all earnings for 12 months 
beginning with the month that the family would 
otherwise be ineligible under the Section 1931 
group. This policy would allow the family to 
remain ehgible under the Section 1931 group for 
12 months regardless of earnings. (NOTE: During 
this period, a family could lose eligibility for a 
reason other than earnings.) At the end of the 12 
months, the State would begin counting the 
earnings, and the family would be ineligible under 
the Section 1931 group. The family would then 
be eligible for TMA for 6-12 months. The State 
may implement this policy through a State plan 
amendment. New Jersey, North Carolina and South 
Carolina have extended transitional Medicaid to 
families in this manner. 

Diversion Payments. Some States provide a 
diversion payment to a family in the month that 
they apply for cash assistance, in lieu of offering 
ongoing cash payments. These payments usually 
go to families that need only temporary help to 
resolve a specific problem that prevents them from 
being self-sufficient. For example, a family might 
not be able to afford to repair a car that is needed 
for employment. Diversion payments are countable 



income for Medicaid purposes unless a State 
chooses to disregard them. A State may use the 
flexibility under Section 1931 to exclude these 
payments from income, thus allowing a family to 
become eligible under the Section 1931 category. 

Disregarding Resources. States have used the 
flexibility available under Section 1931 to: (1) 
simplify the resource test; (2) effectively raise the 
resource standard; or (3) eliminate the resource 
test altogether. 



Alaksa: Transitional Medicaid 

Alaska encourages famiUes receiving 
transitional Medicaid to report decreases in 
income that might enable them to 
reestabhsh eligibility under Section 1931. 
The State also provides a special envelope 
for famihes to save paystubs and receipts 
for child care payments during the 
extended Medicaid period when reports are 
due every three months. 



To simplify the resource test, States have chosen 
to exclude resources that were counted under 
AFDC. For example, a number of States now 
exclude one car of any value. Other States have 
chosen to exclude resources that are not frequently 
encountered or seldom affect eligibility, such as 
the cash value of a life insurance policy. 

Some States have chosen to effectively raise the 
resource standard above that used in AFDC by 
disregarding a flat amount of resources. For 
example, a State which had a resource standard 
of $1000 under AFDC can raise the resource 
standard to $5000 by disregarding $4000 in 
otherwise countable resources. 

Finally, some States have chosen to exclude all 
resources as a less restrictive methodology. This 
effectively eliminates a resource test for the 
Section 1931 group. 



31 



Chapter V 



PROGRAM MONITORING BY STATES 



State oversight of operations at the local 
level is essential if States are to ensure 
consistent and correct application of State 
and Federal policies and procedures. Without 
monitoring of local operations, policy appUcation 
and program practices can vary from county to 
county and there is often no method to alert the 
State to problems occurring in any particular area. 
Many of the TANF delinking problems identified 
by States and CMS were not due to improper 
policies but rather to improper implementation of 
policies at the State or local level. 

A. Minimum Requirements 

Statewide operation. Under Federal law, (Section 
1902(a)(1)), Medicaid State plans must be in 
effect statewide. This requirement applies even 
where counties administer the Medicaid program. 

Monitoring. CMS regulations (42 CFR 431.50) 
require States to ensure that the plan is 
continuously in operation in all local offices by 
informing staff of State policies and procedures 
and through regular monitoring of operations in 
local offices. 

Training and clear instructions to all levels of 
administration, including eligibility workers, are 
part of the State's responsibilities to ensure that 
policies and procedures are correctly and 
consistently applied at the local level as well as 
statewide. 

Review systems and procedures. As part of their 
responsibility to ensure that the State and Federal 
laws and polices are followed statewide. States 
must review their systems and procedures to 
determine if they are functioning properly. For 
example, States must ensure that the systems and 
procedures operating statewide are in compliance 
with Federal requirements to consider all possible 
categories of coverage before denying or 
terminating Medicaid benefits. 



B. Monitoring Strategies 

No one strategy will assure ongoing compliance 
with State and Federal requirements. Some of the 
ways that States have monitored local actions are 
discussed below. 

Visit local offices. Regular visits to local offices 
can help States determine how well they are 
implementing the Medicaid program in 
accordance with Federal and State policies and 
procedures. Interviews with managers and front 
line caseworkers and receptionists can help the 
State assess the level and accuracy of knowledge 
about correct poHcies and procedures, to determine 
where problems are occurring, and to get feedback 
about the office operations. States also should 
review Medicaid eUgibihty manuals, locally- 
generated notices, and other relevant material that 
local offices are using to ensure they have up-to- 
date instructions, policy interpretations and other 
information. 



Georgia: Field Consultants monitor 
program administration. 

Georgia Medicaid program Field 
Consultants monitor, assess and report on 
county offices' Medicaid program 
administration. They visit several county 
offices each quarter, then write and submit 
quarterly reports. These reports identify 
problem areas and provide corrective 
action plans with detailed training 
recommendations, timehnes, and follow-up 
monitoring steps. The Field Consultants 
also attend field coordinator meetings with 
county office directors and provide 
feedback on any counties with problematic 
error rates. 



33 



Monitor and assess the culture in local offices. 

According to recent studies, a significant 
proportion of families deterred from enrolling their 
children cited poor treatment at the local office and 
the need to go to the local office as negative 
factors. States should assess the culture in local 
offices to determine whether the way individuals 
and families are treated may be deterring eligible 
people from seeking or retaining coverage. States 
can consult with community-based organizations, 
consumer advocacy groups, and health care 
providers to get feedback on how local practices 
are affecting family participation. Also, they 
could adopt enrollment goals as a performance 
measure for offices or workers (or both) in order 
to provide incentives for workers to focus their 
efforts on enrolling children and families into 
Medicaid. 



Indiana: Enrollment Goals 

Indiana set county enrollment goals in their 
Hoosier Healthwise (SCHIP Medicaid 
expansion) program. Each local county 
determined their own strategies for 
expanding enrollment of children; the 
central office supported their local decision 
witii regard to outreach implementation 
and monitored data to assess progress 
toward goals. Clear and ongoing 
communication about progress in meeting 
goals, including data, created a 
collaborative spirit. Both state and local 
staff say the county discretion and local 
flexibility contributed to their success in 
meeting and exceeding their enrollment 
goals. 



Meet with Beneficiaries. Beneficiaries can help 
to identify problems in State or local practices 
that are hindering families from enrolling or 
retaining their Medicaid eligibility and they can 
partner with State and local administrators to plan 
ways to improve operations and boost participation. 
Several States have conducted focus groups to 
pinpoint such problems and some States meet 
regularly with consumer groups. 



Monitor enrollment data. Data on denials, 
terminations and enrollment trends for families 
and children, by locality, can alert the State to 
potential problems. For example, declines in 
enrollment in a particular city or county may 
signal the emergence of enrollment or 
reenrollment barriers related to the procedures 
followed in that area. States may also use 
enrollment data as the basis for establishing 
reasonable enrollment goals for State and local 
offices. As seen in the Indiana example, 
enrollment goals help reinforce the importance of 
enrollment as a key objective of State and local 
offices. 

Monitor TANF and Medicaid eligibility 
determination processes. States can develop a 
program of regular monitoring of the 
TANF/Medicaid delinking effort at the local level 
to help ensure that processes in place are working 
properly and do not delay or impede Medicaid 
eligibility determinations or result in erroneous 
Medicaid denials and terminations. Some States 
have established extra supervisory reviews or 
special audits of Medicaid terminations and denials 
that coincide with terminations and denials of cash 
assistance. 

Assess Medicaid and TANF denial and 
termination notices. Incomplete and unclear 
denial and termination notices can contribute to 
misunderstanding about Medicaid eligibility, 
discourage families from pursuing legitimate 
appeals, and deter families from seeking benefits 
in the future (when they may be eligible). A 
review of standardized notices can help to ensure 
that they clearly explain the agency's action and 
reflect current policies. In the case of TANF 
denials and terminations. States should review 
their notices to see if they provide the appropriate 
message regarding the continued availability of 
Medicaid eligibility and provide a phone number 
that individuals can call for assistance. 

Medicaid Eligibility Quality Control (MEQC). 
The MEQC program was enacted as a means to 
reduce high State error rates and monitor the 
accuracy of Medicaid eligibility determinations. 
At that time, Medicaid application and enrollment 



34 



procedures closely followed cash assistance 
program rules. States relied on MEQC 
requirements to help ensure that: (1) Medicaid 
eligibility determinations were accurate; and (2) 
their error rates stayed below the 3 percent 
tolerance level allowed by Federal law. 

CMS regulations (42 CFR 431.800 ff.) set forth 
the process by which States must monitor the 
accuracy of Medicaid eligibility determinations. 
States may follow this process or develop MEQC 
pilots as alternative ways to identify and reduce 
erroneous payments. CMS has an hitemet website 

( http://www.hcfa.gov/medicaid/regions/mqchmpg.htm ') 

that summarizes current State MEQC pilots and 
other information. States can visit this website to 
learn about the ways States are using MEQC to 
help them monitor their programs. 

States also must operate a negative case action 
program (as part of their MEQC activities) 
whereby a sample of Medicaid denied and 
terminated cases are reviewed for accuracy. These 
reviews provide States with data for developing 
corrective actions that improve beneficiary 
protection against erroneous Medicaid denials and 
terminations. States also can develop alternative 
negative case action programs, similar to MEQC 
pilots. 

Some States have voiced concern that the MEQC 
program is a barrier to their efforts to simplify 
Medicaid enrollment procedures. We see no 
evidence that State simplification procedures 
have contributed to an increase in errors and, 
indeed, simplification can reduce erroneous 
denials and terminations. Thus, while MEQC 
remains an important tool for ensuring program 
integrity. States should not view it as a barrier to 
simplification. CMS issued guidance on 
September 12, 2000 that provides examples of 
how MEQC can serve as a valuable aid to 
simplification efforts. In addition, CMS and the 
Office of Inspector General (OIG) issued a letter 
on January 19, 2001 clarifying that program 
integrity is not limited to accurate eligibility 
determinations and payments but also includes 
ensuring that eligible individuals and famihes 



receive the benefits to which they are entitled. 
There is no evidence that program simplification 
strategies designed to make accessing and retaining 
Medicaid benefits easier for individuals and 
families impact proper eligibility determinations. 



Idaho: MEQC Pilot 

Idaho simplified the application process in 
November 1999. This included a shorter 
apphcation form (3 pages), self-declaration 
of income and assets, and twelve 
continuous months of eligibihty. Idaho 
reviews a monthly sample of the SCHIP 
Medicaid expansion cases to determine 
accuracy rates for the approval and denial 
process. Case reviews that show improper 
actions are referred to the regional offices 
for appropriate action. Based on the 
reviews, Idaho determines the accuracy 
rates for the approval and denial process. 
The State has maintained a 99-percent 
accuracy rate for the approval process. The 
accuracy rate for the denial process was 
73-percent for the initial two months but 
has steadily improved to a 93-percent rate 
for the last quarter. Training for specialists 
working the cases has been ongoing, and 
has facihtated the continued improvement 
of accuracy rates for the denial process. 



C. MEQC Strategies to Aid Simplification 
Efforts 

Conduct focused reviews. Eliminating or reducing 
documentation requirements on the family by 
relying on other sources to verify information 
(e.g.. State program files, banks, employers) is 
one way to simplify the application process. 
States can develop MEQC pilots that determine 
whether eliminating certain Medicaid requirements 
on families is impacting the number of erroneous 
eligibility determinations. For example, a State 
could conduct focused reviews to determine if 
self-declaration of resources is affecting the 
accuracy of eligibility determinations. 



35 



Review a targeted sample. States can review 
Medicaid denial cases to determine if Medicaid 
was improperly denied when TANF was denied. 
They can also review Medicaid terminated cases 
to determine if Medicaid was improperly 
terminated when TANF benefits were terminated, 
e.g., due to noncooperation with TANF work 
requirements. 

States also can review a targeted sample of 
Medicaid cases that were denied or terminated 
due to procedural requirements (for example, when 
a person failed to participate in a face-to-face 
interview), and conduct interviews with individuals 
and families to find out why they did not reenroU. 
States could use such findings to help develop 
enrollment practices and procedures designed to 
overcome problems, or to minimize this effect. 



36 



Chapter VI 
TABLE ON SIMPLIFICATION EFFORTS 



States have undertaken numerous strategies 
to make it easier for children to apply for, 
obtain, and retain health coverage, many of 
which are captured in the following tables. 
Simplification strategies have included shortening 
applications, reducing or eliminating 
documentation requirements, lengthening periods 
of eligibility, offering continuous eligibility and 
presumptive eligibility, and streamlining renewal 
processes. 

The following tables provide information about 
States' current application and enrollment 
processes for children as of December 2000. 
These efforts highlight the numerous activities 
States have undertaken to simplify the process for 
children and families to obtain and retain health 
coverage. 



37 



Medicaid/SCHIP Application and Enrollment Simplification Matrix Definitions 

In partnership with State Medicaid and SCHIP agencies and the National Governor's Association, CMS 
has compiled information about States' current application and enrollment processes for 
children. The information in the attached charts was collected from State Medicaid and SCHIP 
agencies and verified by these agencies, as well as the National Governor's Association, before 
publication. The primary purpose of collecting and disseminating information on Medicaid and 
separate child health program application and enrollment simplification efforts is to make available 
comparable, usable, and accurate information. This document will provide operationalized definitions 
of the information collected. 

Application: Information about the application is based upon the State's joint Medicaid/SCHIP 
application. If the State does not have a joint Medicaid/SCHIP application, Medicaid information is 
based upon the Medicaid-only application that children may use, and separate program information is 
based upon the separate program application. If the State does not have a joint Medicaid/SCHIP 
application or a Medicaid-only application that children may use, Medicaid information is based upon 
the Medicaid application available for children to use, including joint Medicaid/TANF applications if 
applicable, and separate program information is based upon the separate program application. 

Application Length: Includes the total number of pages in the application, including instructions 
necessary for completing the application but not including any attached brochures describing program 
benefits. It should be noted, however, that some States include much of the informational material 
about the program with the application while other States include it in a separate brochure. 
Information included as part of the application or instructions was included when determining 
application length, but information contained in separate brochures was not. Most States have made 
efforts to shorten the application children use to apply for Medicaid or SCHIP. When examining the 
length of applications, most of them appeared to be five pages or less. Thus, while the decision to 
classify applications using a five-page threshold was somewhat arbitrary, it seemed the most logical 
place. Short application length is one indicator of a simplified application, but there are many other 
critical factors to consider when determining whether an application is simplified, particularly the 
perceptions of persons filling out the application. 

Application Supplements: Any form necessary for an initial eligibility determinafion that is not 
included in the application, even if it is not required from every applicant. Necessary forms that may 
be completed after the initial eligibility determination is made are not considered application 
supplements. 

Continuous Eligibility: A period of time, specified by the State, during which a child is guaranteed a 
period of eligibility without regard to change in circumstances, except attainment of the maximum age 
or non-payment of premiums if premiums are involved. 

Documentation: Forms or other types of proof of income, expenses, or other eligibility criteria that the 
State requires to verify eligibility. 



38 



Documentation of Earned Income: Proof of earned income so that the apphcant or beneficiary can 
obtain or retain health coverage. Some States may request a specific number of paystubs or 
documentation for a specified period of time (e.g. 1 month, 2 months, etc.). For purposes of this report, 
the specific number of paystubs is listed for States that request a specific number of paystubs. States 
that request documentation for a specified period of time are classified into three categories: (1) States 
that request less than or equal to one month of income documentation, (2) States that request less than 
or equal to three months of income documentation, and (3) States that request more than three months 
of income documentation. States may have different requirements for self-employed 
persons and may also accept alternative forms of documentation such as income tax returns or an 
employer's statement. 

Frequency of Eligibility Renewal: The number of months between regularly scheduled eligibility 
renewals. 

Mail-In Application: An application that may be mailed in and is not followed up with a face-to-face 
interview. States that require face-to-face interviews are not considered to have a mail-in application for 
purposes of this matrix. 

Mail-in Renewal Form: A renewal (redetermination) form that may be mailed in and is not followed 
up with a face-to-face interview. States that require face-to-face interviews are not considered to have a 
mail-in renewal form for purposes of this matrix. 

Medicaid: Columns titled Medicaid include information about children eligible for Medicaid under 
poverty level groups (excluding children eligible under Section 1931), including any Medicaid 
expansions funded by SCHIP dollars. Section 1115 waivers that affect children eligible for Medicaid 
under the poverty level groups are described in a separate line. 

Monthly or Quarterly Reports: Reports that must be submitted by beneficiaries to the Medicaid or 
SCHIP agency as a condition of Medicaid or SCHIP eligibility, regardless of changes in circumstances, 
not including reports required for TANF eligibility, transitional Medicaid, or requirements that changes 
be reported within ten days of occurring. 

Passive Renewal Process: Renewal (redetermination) process in which families do not have to return a 
renewal form unless changes have occurred that might affect ehgibility. 

Pre-Printed Renewal Form: Renewal (redetermination) form which includes a printed copy of the 
information currently in the eligibility file that the family reviews, signs, and returns with any 
appropriate changes. 

Separate Program: Columns titled Separate Program include information about separate child health 
programs funded by SCHIP dollars. 

Separate Renewal Form: Renewal (redetermination) form that is different and distinct from the initial 
application form. 



39 



Application and Enrollment Simplification Profiles 

Medicaid for Children and SCHIP 

December 2000 





State 


5a 


■• 














._ 




•^ SCHIP 


Requested on 1 


















cApplication 


the Application 1 


Medicaid 


Separate 


Medicaid 


Separate 


Medicaid 


Separate 


Medicaid 


Separate 




Medicaid 


Separate 






Program 




Program 




Program 




Program 






Program 


Alabama 


English 
Spanish 


English 
Spanish 


Y 


Y 


N 


N 


Y 


Y 


Y 


N/A 


N/A 


Alaska 


English 


- 


Y 


- 


N 


- 


Y 


- 


- 


N 


- 


American Samoa' 


- 


- 


- 


- 


- 


- 


- 


- 


- 


- 


- 


Arizona 


English 




Y 




N 




Y 






Y 






Spanish 


English 
Spanish 




Y 




N 




Y 


Y 




Y 


1115 Waiver 


English 
Spanish 




Y 




N 




Y 






Y 




Arkansas 


English 




Y 




Y 




Y 






N 






Spanish 


- 




- 




- 




- 


- 




- 


11 15 ArKids Waiver 


English 
Spanish 




Y 




Y 




Y 






N 




California 


English 

Spanish 

Vietnamese 

Cambodian 

Hmong 

Armenian 

Cantonese 

Korean 

Russian 

Farsi 


English 

Spanish 
Vietnamese 
Cambodian 

Hmong 

Armenian 

Cantonese 

Korean 

Russian 

Farsi 


N 


N 


N 


N 


Y 


Y 


Y 


N 


Y 


CNMI 


English 


- 


Y 


- 


Y 


- 


Y 


- 


- 


N/A^ 


- 


Colorado 


English 
Spanish 


English 
Spanish 


Y 


Y 


Y 


Y 


Y 


Y 


Y 


Y 


N/A 


Connecticut 


English 
Spanish 


English 
Spanish 


N 


N 


N 


N 


Y 


Y 


Y 


Y 


Y 


Delaware 


English 




Y 




N 




Y 






Y 






Spanish 


English 
Spanish 




Y 




N 




Y 


Y 




Y 


11 15 Waiver 


English 
Spanish 




Y 




N 




Y 






Y 




DC 


English 
Spanish 




Y 




N 


- 


Y 


- 


- 


Y 


- 


Florida 


English 
Spanish 
Creole 


English 
Spanish 
Creole 


Y 


Y 


N 


N 


Y 


Y 


Y 


Y 


Y 


Georgia 


English 
Spanish 


English 
Spanish 


Y 


Y 


N 


N 


N^ 


Y 


Y 


N 


N 


Guam 


English 


- 


N 


- 


N 




Y 


- 


- 


Y 


- 


Hawaii 


English" 




Y 




Y 




Y 






Y 




1115 Waiver 


English" 




Y 




Y 




Y 






Y 





' American Samoa does not determine eligibility on an individual basis; a system of presumptive eligibility is used. HCFA pays 
expenditures for Medicaid based upon a yearly estimate of the percentage of the population below the poverty level. This estimate is 
approved by HCFA. For Federal Fiscal Year 2001, American Samoa had a total population of approximately 64,500, and the Census 
Bureau estimated that 58.6% of this population, minus an estimated 535 illegal aliens residing in American Samoa, is below the 
poverty level. 

^ CNMI does not collect information on absent parents. Effective October 1989, CNMI began administering its Medicaid program 
under a broad waiver pursuant to 1902(j). This waiver provides them with flexibility to simplify eligibility. Since they do not have a 
TANF program, CNMI bases Medicaid eligibility on the SSI criteria. Prior to the waiver, CNMI did collect absent parent information 
but decided to eliminate this question to simplify the application once it was no longer needed. 

^ Georgia currently has a face-to-face interview requirement, although the interview can be completed at sites other than the welfare 
office and required outstationed sites. The State anticipates eliminating the interview requirement in February 2001. 

" Hawaii provides flyers on Medicaid in several languages, including Korean, Ilacano, Tagalog, Vietnamese, Cambodian, Japanese, 
Chinese, and Samoan, but the State does not have translated applications. 



40 





INITIAL APPLICATION 1 


State 






'"ia|H 




^■Ku . 








■jjbsent Parent 
^Biformation 
^^Cjuested on 


T 


sation 
^of Five 


Appli< 
Supple 


f 








.......... 






^^^:•]\l•z:\'\•:,i 


-■■j^ 1 L/ ■■ H 1*^ '. ' ''J '.'?J 


Medicaid 


Separate 
Program 


Medicaid 


Separate 
Program 


Medicaid 


Separate 
Program 


Medicaid 


Separate 
Program 




Medicaid 


Separate 
Program 


Idaho 


English 
Spanish 


- 


Y 


- 


N 


- 


Y 


- 


- 


N 


- 


Illinois 


English 
Spanish 


English 
Spanish 


Y 


Y 


N 


N 


Y 


Y 


Y 


Y 


Y 


Indiana 


English 
Spanish 


English 
Spanish 


Y 


Y 


Y 


Y 


Y 


Y 


Y 


N 


N 


Iowa 


English 
Spanish 


English 
Spanish 


Y 


Y 


N 


N 


Y 


Y 


Y 


Y 


N/A 


Kansas 


English 
Spanish 


English 
Spanish 


Y 


Y 


N 


N 


Y 


Y 


Y 


Y 


Y 


Kentucky 

1115 Waiver 


English 
Spanish 

English 
Spanish 


English 
Spanish 


Y 
Y 


Y 


N 
N 


N 


Y 
Y 


Y 


Y 


Y 
Y 


Y 


Louisiana 


English 
Spanish 


- 


Y 


- 


N 


- 


Y 


- 


- 


Y 


- 


Maine 


English" 


English' 


Y 


Y 


N 


N 


Y 


Y 


Y 


N 


Y 


Maryland 


English 
Spanish 


- 


Y 


- 


N 


- 


Y 


- 


- 


Y 


- 


1115 Waiver 


English 
Spanish 




Y 




N 




Y 






Y 




Massachusetts 

1115 Waiver 


English 
Spanish 

English 
Spanish 


English 
Spanish 


Y 
Y 


N 


Y 
Y 


Y 


Y 
Y 


Y 


Y 


Y 
Y 


Y 


Michigan 


English 
Spanish 
Arabic 


English 
Spanish 
Arabic 


N 


Y 


N 


N 


Y 


Y 


Y 


Y 


Y 


Minnesota 


English 
Spanish 

Cambodian 
Hmong 
Laotian 
Russian 
Somali 

Vietnamese 




N 




N 




Y 






N 




1115 Minnesota 
Care Waiver 


English 
Spanish 

Cambodian 
Hmong 
Laotian 
Russian 
Somali 

Vietnamese 




N 




N 




Y 






N 




Mississippi 


English 
Spanish 


English 
Spanish 


Y 


Y 


Y 


Y 


Y 


Y 


Y 


Y 


Y 


Missouri 


English 

Spanish 

Bosnian 

Vietnamese 




Y 




N 




Y 






Y 




1115 MC+ Waiver 


English 

Spanish 

Bosnian 

Vietnamese 




Y 




N 




Y 






Y 




Montana 


English 


English 


N 


N 


Y 


N 


Y 


Y 


Y 


N 


N/A 


Nebraska 


English 
Spanish 
Vietnamese 
Russian 
Arabic 




Y 




N 




Y 






N 





' Instructions are also provided in French, Amharic, Acholi, Somali. Arabic, Farsi, Russian, Chinese. Albanian, Vietnamese, and 
Bosnian (Serbo-Croation). 



41 







,MiS', 


s^wlNITIAL APPLICATION 




'»»S'WISi* 


1 








■1 






m 






m 


Absent Parent 1 












^~iT^^ 


■Ki- 






"T"" 


Information 1 


state 




















; Requested on 1 




**|]^r-wi».T;i>r^>^fnT>^^ 


Medicaid 


Separate 


Medicaid 


Separate 


Medicaid 


Separate 


Medicaid 


Separate 




Medicaid 


Separate 






Program 




Program 




Program 




Program 






Program 


Nevada 


English 
Spanish 


English 
Spanish 


Y 


Y 


N 


N 


Y 


Y 


N 


Y 


Y 


New Hampshire 


English 


English 


Y 


Y 


N 


N 


Y 


Y 


Y 


Y 


Y 


New Jersey 


English 
Spanish 


English 
Spanish 


N 


N 


N 


N 


Y 


Y 


Y 


Y 


Y 


New Mexico 


English 
Spanish 




Y 




N 




N^ 






N 




1115 Waiver 


English 
Spanish 




Y 




N 




N^ 






N 




New York 


English' 




N 




N 




N" 






N 








English' 




N 




N 




Y 


Y 




N/A 


1115 Waiver 


English' 




N 




N 




N' 






N 




North Carolina 


English 
Spanish 


English 
Spanish 


N 


N 


N 


N 


Y 


Y 


Y 


Y 


Y 


North Dakota 


English 


English 


N 


Y 


N 


N 


Y 


Y 


N 


Y 


N/A 


Ohio 


English 
Spanish 




Y 




N 




Y 






N 




1115 Waiver 


English 
Spanish 




Y 




N 




Y 






N 




Oklahoma 


English 
Spanish 




Y 




N 




Y 






N 




1115 Waiver 


English 
Spanish 




Y 




N 




Y 






N 




Oregon 


English 

Spanish 

Vietnamese 

Cambodian 




N 




N 




Y 






N 






Romanian 


English 




N 




N 




Y 


Y 




Y 




Hmong 


Spanish 






















Mien 


Vietnamese 






















Russian 


Cambodian 






















Lao 


Romanian 
Hmong 




















1115 Waiver 


English 

Spanish 

Vietnamese 

Cambodian 

Romanian 

Hmong 

Mien 

Russian 

Lao 


Mien 

Russian 

Lao 


N 




N 




Y 






N 




Pennsylvania 


English 
Spanish 


English 
Spanish 


N 


N 


N 


N 


Y 


Y 


Y 


Y 


Y 


Puerto Rico 


English 
Spanish 


- 


Y 


- 


N 


- 


N 


- 


- 


N 


- 


Rhode Island 


English 




N 




N 




Y 






Y 






Spanish 






















1115 Waiver 


English 
Spanish 




N 




N 




Y 






Y 




South Carolina 


English 
Spanish 


- 


Y 


- 


N 


- 


Y 


- 


- 


Y 


- 


South Dakota 


English 


. 


Y 


- 


Y 


- 


Y 


- 


- 


N 


- 


Tennessee^ 
























1115 Medicaid 


English 




Y 




N 




N'° 




Y 


Y 




1115 Expansion 


English 




Y 




N 




ylO 






Y 





^ Although New Mexico still has a face-to-face interview requirement, the interview can be completed at locations other than the 

welfare office and required outstationed sites. 
' A Spanish application is currently being developed. 
* Although New York still has a fact-to-face interview requirement, the interview can be completed at locations other than the welfare 

office and required outstationed sites. 



42 







state 




^^^Bcation Applic|n| 
^^^Hl of Five Supple^m 


1 








sent Parent 1 






.:,,-■;--. 






1 


Medicaid 


Separate 
Program 


Medicaid 


Separate 
Program 


Medicaid 


Separate 
Program 


Medicaid 


Separate 
Program 




Medicaid 


Separate 
Program 


Texas 


English 
Spanish 


English 
Spanish" 


Y 


Y 


Y 


N 


N 


Y 


N^^ 


Y 


N 


Virgin Islands 


English 


- 


Y 


- 


N 


- 


N 


- 


- 


Y 


- 


Utah 


English 
Spanish 


English 
Spanish 


Y 


Y 


Y 


Y 


N 


N 


N 


Y 


N/A 


Vermont 
1115 Waiver 


English 
English 


English 


Y 
Y 


Y 


N 
N 


N 


Y 
Y 


Y 


Y 


N 
N 


N 


Virginia 


English 
Spanish 


English 
Spanish 


Y 


Y 


Y 


Y 


Y 


Y 


Y 


Y 


Y 


Washington 


English 

Spanish 

Vietnamese 

Cambodian 

Russian 

Ukrainian 

Mandarin 

Taglog 


English 

Spanish 

Vietnamese 

Cambodian 

Russian 

Ukrainian 

Mandarin 

Taglog 


Y 


Y 


N 


N 


Y 


Y 


Y 


Y 


Y 


West Virginia 


English 


English 


Y 


Y 


N 


N 


N" 


Y 


Y 


Y 


N 


Wisconsin 

1115 Badger Care 
Waiver 


English 
Spanish 
Hmong 

English 
Spanish 
Hmong 


- 


Y 
Y 


- 


N 
N 


- 


N 
N 


- 


- 


Y 
Y 


- 


Wyoming 


English 


English 


Y 


Y 


Y 


Y 


N'^ 


Y 


Y 


Y 


N/A 



Tennessee operates a 1 1 15 waiver with two separate populations that have somewhat different eligibility rules. The population 

referred to here as the 1115 expansion includes previously uninsured and uninsurable persons. 

Medicaid "rollovers", those terminated from Medicaid but eligible for TennCare as uninsured, may mail in their application. 

Uninsurabies may mail in their application. Uninsured applicants and SCHIP applicants may mail in their application but must have a 

face to face interview. Any applicant for Medicaid or the expansion population who is disabled or otherwise cannot apply in person 

may mail in their application and have an application interview by telephone. 

Texas will also accept the Spanish application created by Covering Kids. 
12 

Texas accepts the SCHIP application used by Tex Care Partnership for Medicaid as well 

'^ West Virginia does not require face to face interviews if the joint Medicaid/SHIP application is used and is referred to Medicaid. 

Effective April 1, 2001, Wyoming will remove all face-to-face interview requirements. 



43 



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47 



Application and Enrollment Simplification Profiles 

Medicaid for Children and SCRIP 

December 2000 



. ^ifir.*.7^»^'*7' *sniv 






ONQSUiaiUgi 


^iHi 


liyij 




-■d 








^^^^H Continuou^^^H 




iique 


m 


m^ly or Quarterly | 










. ■ ' 


T - -■---'■; .|-J 1 


State 


Medicaid 


Separate 
Program 


Medicaid 


Separate 
Program 


Medicaid 


Separate 
Program 


Alabama 


12 months 


12 months 


12 months 


12 months 


N 


N 


Alaska 


12 months 


- 


12 months 


- 


N 


- 


American Samoa' 


- 


- 


- 


- 


- 


- 


Arizona 
11 15 Waiver 


12 months 
12 months 


12 months 


12 months 
12 months 


12 months 


N 
N 


N 


Arkansas 
11 15 ArKids Waiver 


N 
12 months 


- 


12 months 
12 months 


- 


N 
N 


- 


California 


12months'' 


12 months 


12 months 


12 months 


N^ 


N 


CNMI 


N 


- 


12 months" 


- 


N 


- 


Colorado 


N 


12 months 


12 months 


12 months 


N 


N 


Connecticut 


12 months 


12 months 


12 months 


12 months 


N 


N 


Delaware 
1115 Waiver 


N 
N 


12 months 


12 months 
12 months 


12 months 


N 
N 


N 


DC 


N 


- 


12 months 


- 


N 


- 


Florida 


12 months' 


6 months'" 


12 months 


6 months 


N 


N 


Georgia 


N 


N 


6 months 


12 months 


3 months 


N 


Guam 


N 


- 


6 months 


- 


N 


- 


Hawaii 
11 15 Waiver 


N 
N 


- 


12 months 
12 months 


- 


N 
N 


- 


Idatio 


12 months 


- 


12 months 


- 


N 


- 


Illinois 


12 months 


12 months 


12 months 


12 months 


N 


N 


Indiana 


12 months 


12 months 


12 months 


12 months 


N 


N 


Iowa 


N 


12 months 


12 months 


12 months 


N 


N 


Kansas 


12 months 


12 months 


1 2 months 


1 2 months 


N 


N 


Kentucky 

11 15 Waiver 


N 
N 


N 


12 months 
12 months 


12 months 


N 
N 


N 


Louisiana 


12 months 


- 


12 months 


- 


N 


- 


Maine 


6 months 


6 months 


6 months 


6 months 


N 


N 


Maryland 
11 15 Waiver 


N^ 
N^ 


- 


12 months 
12 months 


- 


N 

N 


- 


Massactiusetts 
1115 Waiver 


N 
N 


N 


12 months 
12 months 


12 months 


N 
N 


N 


Mictiigan 


N 


1 2 months 


12 months 


12 months 


N 


N 


Minnesota 

1115 

MinnesotaCare 

Waiver 


N 

N 


- 


12 months 
12 months 


- 


N 
N 


- 


Mississippi 


12 months 


12 months 


12 months 


12 months 


N 


N 



' American Samoa does not determine eligibility on an individual basis; a system of presumptive eligibility is utilized. HCFA pays 
expenditures for Medicaid based upon a yearly estimate of the percentage of the population below the poverty level. This estimate is 
approved by HCFA. For Federal Fiscal Year 2001, American Samoa had a total population of approximately 64,500, and the Census 
Bureau estimated that 58.6% of this population, minus an estimated 535 illegal aliens residing in American Samoa, is below the 
poverty level. 

^ Effective January 1 , 200 1 

^ Effective January 1, 2001 

■* Families who have fluctuating income due to the nature of their work, such as seasonal employment or overtime, are redetermined 
eligible every 3 or 6 months. 

^ Continuous eligibility is extended to children age 5 and under. 

* Children who enroll in the State's managed care program will receive 6 months guaranteed coverage even if they become ineligible. 



48 



li-^'^timi^mK^yii^i:,^ >':.,-. '^,£.:, 1 1 r' 1 ilMIMI 


ONGOING ELIGIBILITY 1 


state 






^ Frequency of „ ^^atU^r Quarterly 
Biiqibilitv RenewaiH HHIBna Cvcle 


Medicaid 


Separate 
Program 


Medicaid 


Separate 
Program 


Medicaid 


Separate 
Program 


Missouri 
11 15 MC+ Waiver 


N 
N 


- 


12 months 
12 months 


- 


N 
N 


- 


Montana 


N 


12 months 


12 months 


12 months 


N 


N 


Nebraska 


12 months 


- 


12 months 


- 


N 


- 


Nevada 


N 


12 months 


12 months 


12 months 


N 


N 


New Hampshire 


N' 


N» 


12 months 


12 months 


N 


N 


New Jersey 


N 


N 


12 months 


12 months 


N 


N 


New Mexico 

1115 Waiver 


12 months 

12 months 


- 


12 months 
12 months 


- 


N 

N 


- 


New York 
11 15 Waiver 


12 months 
12 months 


N 


12 months 
12 months 


12 months 


N 
N 


N 


Nortti Carolina 


12 months 


12 months 


12 months 


12 months 


N 


N 


North Dakota 


N 


12 months 


12 months 


12 months 


1 month 


N 


Ohio 
11 15 Waiver 


N 
N 


- 


12 months 
12 months 


- 


N 
N 


- 


Oklahoma 
11 15 Waiver 


N 
N 


- 


6 months 
6 months 


- 


N 
N 


- 


Oregon 
1115 Waiver 


N 
N 


N 


6 months 
6 months 


6 months 


N 
N 


N 


Pennsylvania 


N 


12 months 


12 months 


12 months 


N 


N 


Puerto Rico 


N 


- 


6 months 


- 


N 


- 


Rhode Island 
1115 Waiver 


N- 


- 


12 months 
12 months 


- 


N 
N 


- 


South Carolina 


12 months 


- 


12 months 


- 


N 


- 


South Dakota 


12 months 


- 


12 months 


- 


N 


- 


Tennessee"" 
1115 Medicaid 

1115 Expansion 


12 months 
12 months 


- 


12 months 
12 months 


- 


N 
N 


- 


Texas 


N 


12 months 


6 months 


12 months 


N 


N 


Virgin Islands 


N 


- 


6 months 


- 


N 


- 


Utah 


N 


12 months 


12 months 


12 months 


N 


N 


Vermont 

1115 Waiver 


N 

N 


N 


12 months 
12 months 


12 months 


N 
N 


N 


Virginia 


N 


N 


12 months 


12 months 


N 


N 


Washington 


12 months 


12 months 


12 months 


12 months 


N 


N 


West Virginia 


N 


12 months 


12 months 


12 months 


N 


N 


Wisconsin 

1115 Badger Care 
Waiver 


N 
N 


- 


12 months 
12 months 


- 


N 
N 


- 


Wyoming 


N^^ 


12 months 


6 months" 


12 months 


N 


N 



Children \\ho enroll in the State's \oluntary managed care program will receive 6 months guaranteed coverage even if they become 

ineligible for Healthy Kids Gold (Medicaid). 
'^ Children in Healthy Kids Silver (SCHIP) will recei\'e 6 months guaranteed co\erage even if they are become ineligible for Healthy 

Kids Silver except if they turn 19, are not longer resident of the State, or fail to pay the premium. 

Medicaid children are guaranteed 6-month coverage under managed care except if the child ages out or leaves the state. 
'" Tennessee operates a 11 1 5 waiver with two separate populations that have somewhat different eligibility rules. The population 

referred to here as the 1115 expansion includes pre\iously uninsured and uninsurable persons. 
" Effective April 1. 2001. Wyoming will offer 12 months of continuous eligibilit\' for Medicaid and move to annual renewals. 



49 



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54 



CONCLUSION 



This guide is intended to help States ensure 
that low-income families and individuals 
are properly considered for Medicaid, 
whether or not they have applied for or ever 
received cash assistance, and to improve 
Medicaid access and retention for all applicants 
and beneficiaries. Medicaid coverage provides 
critical health care to families who are entering 
the workplace, as well as to families who work at 
jobs that do not offer affordable health care. 
Medicaid is no longer an adjunct to cash 
assistance; it is a health care program offering 
coverage, largely through the purchase of 
managed care, to a broad group of low-income 
children and an expanding group of low-income 
famiUes. Together, Federal, State and local 
Medicaid agencies must adapt to these changes, 
overcome public misperceptions about Medicaid, 
and, in some cases, reorient their way of doing 
business in order to promote participation among 
eligible children and families. 



■ 



55 



MS Library i" 

C2-07-13 ( 

7500 Secui icy Bivd. \ 

Bi-iltlmorS; I'^ar/tend 21244 ■■